14 year old boy brought in by parents with abdominal pain. Pain was vague when it started yesterday. Today it is more persistently located in the right lower quadrant. The child has some nausea but no emesis. Temp of 100.8 °F. Exam reproduces RLQ tenderness but no rebound, no guarding.

No other concerning symptoms.

You discuss your concern for appendicitis with his parents, order labs and then bring the ED ultrasound to the bedside. You begin by scanning the area of maximal discomfort with a linear probe but do not find any abnormalities. You bring the probe down to the iliac vessels and obtain this clip.

In this clip we see the iliac vessels on the right side in far field. The center of the image, in short axis, we see a tubular structure with hypoechoic walls lying over the psoas muscle.

Obtaining a long axis view of this structure we find that is blind, ending and non-compressible.

Measuring in short axis, we find that this structure has a diameter of 10 mm or 1 cm.

With a present history and exam consistent with appendicitis the finding of a 10 mm non-compressible, blind ending structure in the right lower quadrant makes appendicitis very likely. The on call general surgeon is called.

Education:

We have an educational process in place. 

1. You should have the opportunity to practice nerve blocks at your next Bioskills training.
2. You can spend time in the PACU with our local block expert Attila Kett.  Text me and I can slot you into a week.  Usually we touch base with him on Mondays and the most high yield day is Thursdays when a lot of ortho cases are going.  It is a nice day – meet in the PACU at 7am.  I would stay until all the ortho cases were done – about 6 hours.
3. Call anesthesia – they will bring their equipment down to have the block done, but are willing to walk you through a block.
4. If anesthesia is unable to come to the ED for your hip fracture, call me.  If I can make it, I’ll come in and do the block with you so you can teach the next person.
5. There are online resources available at nwhed.org, including a review of the fascia iliaca block we will be using, the nerve block checklist which can be printed prior to the procedure, guidance on LAST treatment and the EMSL Guideline.
6. For ultrasound savvy folks, 2 observed blocks are required per EMSL guidelines, and for the novice, 10 blocks are required.

Order Set

For the procedure itself, there is an order set in meditech, titled ED: Nerve Block.  The orders for anesthetic are here as well as for Intralipid in the exceedingly rare case of a patient with LAST (local anesthetic systemic toxicity).  You can use this order set for any other local or regional blocks you are doing should you suspect LAST.

Procedure Cart

The new procedure cart should have a Nerve Block Kit, probe sheath and block needle which you will need for the procedure.

Documentation

You can document the procedure using the .usnerveblock or .usblock dotphrases/quicktexts. This can be anywhere in your note, but would be appropriate to place in the “ultrasound” tab.

Complications

Again, complications are very rare.  There is always the possibility of hematoma, or infection when you go through the skin.  These patients will be on the monitor to screen for signs of LAST toxicity.  LAST may begin with tinnitus, perioral numbness, and then cardiac signs – tachycardia, hypertension.  These may progress to seizure > coma > death.  Again this is exceedingly rare and the treatment is in the pyxis with dosing in the order set if needed.  Nursing education has done a great job of bringing our nurses up to speed.

Hit me up with any questions, but especially if you want to spend time in the PACU – our new chief is going to be one of the first to spend time up there!

• In response to the ongoing and extensive global outbreak of highly pathogenic avian influenza
  (HPAI) A(H5N1) in wild birds, poultry, and dairy cattle, the Centers for Disease Control and
  Prevention (CDC) is encouraging year-round testing for influenza among persons with severe
  respiratory illness.
• NYSDOH and the CDC request that respiratory samples from persons hospitalized with
  laboratory confirmed influenza, particularly patients receiving intensive care unit (ICU) level care,
  be promptly forwarded to the Wadsworth Center Virology Laboratory for additional testing,
  including subtyping, whole genome sequencing, and antiviral resistance testing.
• Laboratories, hospitals, and clinical providers should recognize that adherence to
  recommendations for influenza testing and sample submission are important steps for human
  HPAI A(H5N1) surveillance in the United States (U.S.), especially during the summer when
  influenza testing may not be routine and exposure to poultry, cattle, and swine may increase
  during agricultural fair season.
• If you suspect a patient has a novel influenza A virus infection based on an influenza A
  positive laboratory result in combination with clinical history and exposures, immediately
  contact the NYSDOH at 518-473-4439 or 1-866-881-2809 after hours and the local health
  department (LHD)1 where the patient resides.
  1 https://www.health.ny.gov/contact/contact_information/
  Health Advisory: Influenza Testing among Persons with Severe Respiratory Illness
  During Periods of Low Influenza Virus Circulation
  Please distribute immediately to: Clinical Laboratories, Hospitals, Local Health Departments,
  Physicians, Physician Assistants, Nurses, Nurse Practitioners, Facility Staff in The Departments of
  Emergency Medicine, Infectious Disease, Infection Prevention and Control, Epidemiology,
  Laboratory Medicine, Medical Directors, Directors of Nursing, and all patient care areas
  Page 2 of 3
  Background
  Public health agencies in the U.S. and clinical partners continue to monitor and respond to the global
  outbreak of HPAI A(H5N1). As of July 18, more than 100 million poultry have been affected in 48
  states in the current U.S. outbreak, the largest domestic outbreak of avian influenza in poultry in
  recorded history. Additionally, HPAI A(H5N1) has been detected in more than 163 U.S. dairy cattle
  herds in 13 states and sporadically in other animals2
  .
  The currently circulating strain of HPAI A(H5N1) poses a low risk to the health of the general public.
  However, to date, nine human cases of A(H5N1) infection associated with the outbreak in U.S. dairy
  cows3 and poultry4 have been reported. While the number of human cases nationally remains small,
  influenza viruses are known to be unpredictable and highly mutable with the potential for a rapid
  change in tropism and transmission, which is a concern given the extent of spread in birds and novel
  detections in dairy cows and other animals.
  Please visit https://www.cdc.gov/bird-flu/situation-summary/index.html for the most up-to-date
  information.
  Recommended actions:

1. Submit to Wadsworth Center year-round all positive influenza samples from hospitalized
   patients requiring ICU care.
2. Conduct enhanced influenza surveillance during months when seasonal influenza
   incidence is typically low (May through September).

• Continue ordering influenza testing and subtyping on patients with respiratory illness.
• NYSDOH recommends increased levels of clinical suspicion of influenza in patients with
  respiratory illness who are at higher risk for contracting avian or novel influenza, such as those
  with a history of exposure to dairy cattle, wild birds, poultry, or swine (pigs).
• If you have a patient with conjunctival symptoms (with or without respiratory symptoms) and who
  is at high risk for contracting avian or novel influenza, such as recent exposure to dairy cattle,
  contact the local health department (LHD)5 where the patient resides for testing guidance. If
  unable to reach the LHD where the patient resides, contact the NYSDOH Bureau of
  Communicable Disease Control at 518-473-4439 during business hours or at 866-881-2809
  after hours.

1. Submit to Wadsworth Center all influenza positive samples detected in hospitalized
   persons NOT requiring ICU care until December 31, 2024, for subtyping, sequencing,
   and other specialized analyses, as well as potentially forwarding to CDC for their repository.

• In the event of an outbreak, please contact the NYSDOH at 518-473-4439 for guidance.
  Specimen and shipping instructions
• Specimens acceptable for influenza testing at Wadsworth Center include nasopharyngeal swabs
  (NPs), oropharyngeal swabs (OPs), and nasal swabs (NSs) in viral transport media (VTM) or
  universal transport media (UTM).
• Flocked swabs are preferred. Sterile Dacron® or rayon swabs with plastic or metal handles may
  also be used. Do NOT use cotton or calcium alginate swabs or swabs with wooden sticks. Place
  the swab in liquid VTM or UTM. The swabs and media used for routine SARS-CoV-2 or influenza
  (polymerase chain reaction (PCR)) testing can be used. Do NOT use saline or dry swabs.
• Specimens MUST be kept cool until they reach Wadsworth Laboratory. Refrigerate OR store
  specimens in cooler with frozen gel packs until ready to ship. Specimens should be shipped
  2 https://www.cdc.gov/bird-flu/situation-summary/index.html
  3 https://www.cdc.gov/media/releases/2024/p-0703-4th-human-case-h5.html
  4 https://www.cdc.gov/media/releases/2024/p-0715-confirm-h5.html
  5 https://www.health.ny.gov/contact/contact_information/
  Page 3 of 3
  overnight on frozen gel packs.
• Specifics regarding influenza specimen collection and shipping to Wadsworth Center can be
  found at: https://www.wadsworth.org/programs/id/virology/services/specimen-collection
• A shipping manifest from an electronically submitted Remote Order OR an Infectious Disease
  Requisition (IDR)6
  form requesting influenza testing with subtyping should accompany all
  specimens sent to Wadsworth.
• For questions about shipping on holidays or weekends, please call 518-474-4177.
• Please ship specimens to:
  David Axelrod Institute
  Virology Laboratory
  Wadsworth Center
  New York State Dept. of Health
  120 New Scotland Ave.
  Albany, NY 12208
  Infection Prevention Considerations
  Standard, Contact, and Airborne precautions, including the use of eye protection, are
  recommended for the collection of respiratory and other specimens and medical evaluation.
• Patients with suspected HPAI A(H5N1) infection who present to a healthcare facility should be
  placed in an airborne infection isolation room (AIIR).
• If a patient presents to a healthcare facility at which an AIIR is not available, the patient should
  be instructed to wear a facemask and should be placed in an examination room with the door
  closed until discharge or transfer to a facility with an AIIR.
• Additional infection prevention and control guidance for healthcare facilities with or without an
  AIIR, including additional patient placement information and cleaning and disinfection steps, is
  available7
  .
  NYSDOH appreciates your continued support in this effort to prevent and control influenza, and
  the partnership with laboratories, hospitals, and providers to immediately identify and contain
  potential human cases of novel influenza in the U.S.
  Resources and Questions
• Questions regarding submission of specimens to Wadsworth Center can be directed to
  wcid@health.ny.gov.
• Questions pertaining to enrollment to Wadsworth Center CLIMS for access to remote ordering and
  access to electronic test reports can be directed to climsoutreach@health.ny.gov.
• General questions about suspected A(H5N1) cases can be directed to the NYSDOH BCDC at 1-
  866-881-2809 evenings, weekends, and holidays or by email at BCDC@health.ny.gov.
• NYC based clinicians should contact the healthcare provider access line at 1-866-692-3641
• General questions about influenza infection control in hospitals, nursing homes, and diagnostic and
  treatment centers can be sent to icp@health.ny.gov
• Additional NYSDOH guidance for clinicians regarding Highly Pathogenic Avian Influenza A(H5N1)
  is available at: https://commerce.health.state.ny.us/hpn/ctrldocs/alrtview/postings/NY_Advisory_-
  _HPAI_Identification_of_Human_Infection_2024_1712853441619_0.0.pdf
• General NYSDOH avian influenza information is available at:
  https://www.health.ny.gov/diseases/communicable/influenza/avian/
  6 https://www.wadsworth.org/programs/id/idr
  7 https://www.cdc.gov/bird-flu/hcp/novel-flu-infection-control/?CDC_AAref_Val=https://www.cdc.gov/flu/avianflu/novel-flu-infection-control.htm

• Carfentanil, a potent synthetic opioid that is estimated to be up to 100 times stronger than fentanyl,
  has been identified in New York City multiple recent samples sold as opioids. Similarly,
  medetomidine, a non-opioid anesthetic similar to xylazine, has also been identified in the NYC drug
  supply, specifically in the Bronx, for the first time.
• Between March and June 2024, the NYC Health Department’s drug-checking program has
  identified trace and small amounts of carfentanil in eight samples sold as opioids. All samples
  containing carfentanil also contained fentanyl.
  o Carfentanil was not detected via point-of-care drug-checking technologies (e.g., Fourier
  transform infrared spectrometry and fentanyl test strips) due to the technologies’ limitations.
  Carfentanil in these samples was detected through secondary laboratory testing.
  o Although carfentanil was only identified in trace and small amounts, two of the eight samples
  were associated with adverse reactions, including overdose.
• According to data from the NYC Health Department’s Bureau of Vital Statistics and NYC Office of
  the Chief Medical Examiner, carfentanil was also involved in at least seven unintentional drug
  overdose deaths between January and June 2024, an increase from at least three unintentional
  drug overdose deaths in 2023. These data are provisional and subject to change.
• The New York State Department of Health Community Drug-Checking Program identified
  medetomidine in an opioid sample collected in the Bronx. Although naloxone cannot reverse the
  effects of medetomidine, this substance has most often been found with opioids. Consequently, it is
  important to use naloxone even in the case of a suspected medetomidine-involved overdose.
• Contact the NYC Health Department immediately if you observe or learn of unusual overdoses or
  other adverse events, including those with symptoms consistent with the novel substances
  described above.
  July 25, 2024
  Dear Colleagues,
  The New York City Department of Health and Mental Hygiene (NYC Health Department) operates a multisite drug-checking program in partnership with five syringe service programs. Over the past four months,
  eight opioid samples collected in the Bronx, Brooklyn, and Manhattan and sent for secondary laboratory
  testing were found to contain trace or small amounts of carfentanil. All samples found to contain carfentanil
  also contained fentanyl, which was detected by NYC Health Department drug-checking technicians through
  Fourier transform infrared spectrometry (FTIR) or fentanyl test strips (FTS). Of the eight samples identified
  to contain carfentanil via secondary testing, two were associated with adverse reactions, including
  overdose. Both of these samples contained fentanyl and xylazine.
  Carfentanil is a potent synthetic opioid that is estimated to be up to 100 times stronger than fentanyl. Due
  to its potency, substances containing even small amounts of carfentanil can cause immediate and severe
  adverse reactions including overdose, especially for individuals with low opioid tolerance. Like other
  opioids, the effects of carfentanil can be reversed with the administration of naloxone. Although multiple
  doses of naloxone may be needed, the NYC Health Department discourages the use of 8mg naloxone
  among lay-persons and first-responders, as it has not been found to be more effective than 4mg naloxone
  and can increase the risk of precipitated opioid withdrawal.
  Providers should educate individuals who use drugs about the presence of carfentanil in the unregulated
  opioid supply in NYC, and caution that carfentanil may not be reliably detected through FTS or FTIR testing
  alone. Nevertheless, as carfentanil has only been found in combination with fentanyl, providers should
  continue to encourage individuals to test their drugs using FTS or drug-checking services and take further
  steps to reduce their risk of overdose.
  Medetomidine has also been identified for the first time in the NYC drug supply. An opioid sample collected
  from the Bronx by the New York State Department of Health Community Drug Checking program in late
  June 2024 was found to contain medetomidine via secondary laboratory testing. This sample was also
  found to contain fentanyl. Adverse reactions associated with this specific sample are not known.
  Medetomidine is a non-opioid anesthetic that is FDA-approved for veterinary use. It is similar to xylazine,
  but is more potent and causes longer-lasting effects. At this time, medetomidine cannot be differentiated
  from dexmedetomidine (Precedex)—a sedative which is FDA-approved for human use—through
  secondary laboratory testing.
  As medetomidine/dexmedetomidine are not opioids, naloxone cannot reverse the effects of these
  substances. However, since medetomidine/dexmedetomidine have most often been found with fentanyl
  and other potent opioids, it is important to use naloxone even in the case of a suspected
  medetomidine/dexmedetomidine-involved overdose. Individuals may still be sedated after naloxone
  reversal of opioid-induced respiratory depression. For this reason, it is important to administer rescue
  breathing, place individuals in a rescue position to protect their airways, and continue to monitor their
  breathing with a pulse oximeter. Call emergency services to facilitate access to further monitoring and
  administration of supplemental oxygen.
  Clinical Information on Carfentanil:
• Carfentanil is a synthetic opioid which is estimated to be up to 100 times stronger than fentanyl.
• Symptoms of a carfentanil- or fentanyl-involved overdose are characterized by central nervous
  system and respiratory depression: lethargy, slowed or shallow breathing, pinpoint pupils, change in
  consciousness, seizure, and/or coma.
• Treatment is the same as for other opioid overdoses; however, if there is no return of spontaneous
  breathing, additional naloxone doses may be required to reverse the opioid effects.
• Due to the presence of xylazine in the unregulated opioid supply, individuals may still be sedated
  after naloxone reversal of opioid-induced respiratory depression. In cases of stopped or irregular
  breathing, rescue breathing should be administered in addition to naloxone.
  Clinical Information on Medetomidine/Dexmedetomidine:
• Similar to xylazine, medetomidine is a synthetic alpha-2 adrenoreceptor agonist sedative used in
  veterinary medicine. Medetomidine is used for sedation, analgesia, muscle relaxation and
  anxiolysis (i.e., anti-anxiety).
• The effects of medetomidine intoxication may include: extreme sedation, slower than usual heart
  rate (reportedly as low as 40 beats per minute), low blood pressure, and central nervous system
  depression. Someone experiencing medetomidine intoxication may be unresponsive to verbal
  commands or physical stimuli even though they may still be breathing.
• Medetomidine is not an opioid, so the effects of medetomidine cannot be reversed with the
  administration of naloxone.
• Since medetomidine has most often been found with fentanyl and other opioids, naloxone should
  be administered in all suspected overdoses involving medetomidine. Rescue breathing or
  supplemental oxygen should be administered in cases of stopped or irregular breathing.
  Recommendations
• Contact the NYC Health Department immediately if you observe or learn of unusual overdoses
  or other adverse events, including those with symptoms consistent with the novel substances
  described above.
  o If possible, consider saving small amounts (at least half of a grain of rice) of substances
  associated with reported adverse events to submit to the NYC Health Department. The NYC
  Health Department drug-checking team can send samples to our partner laboratory for
  testing and timely identification of substances.
  o The NYC Health Department drug-checking team can be reached at
  drugchecking@health.nyc.gov.
  o For drug-checking services and inquiries outside of New York City, the NYS Department of
  Health drug-checking team can be reached at drug.checking@health.ny.gov.
• Consider potential xylazine or medetomidine exposure for patients who present with suspected
  overdoses and who continue to experience prolonged sedation following naloxone administration.
• Provide person-centered, trauma-informed care to patients who use drugs, including wound
  care and withdrawal management, even if they are not ready to stop using.
  o For trainings on addressing substance use stigma in health care settings and other provider
  resources, click here.
• Counsel patients who use drugs about overdose risk reduction strategies including avoiding using
  drugs alone and avoiding mixing drugs (including alcohol).
  o Recommend that patients who are planning to use drugs alone call the “Never Use
  Alone” hotline at 877-696-1996.
  o Click here for more overdose prevention resources for providers, including tools to talk to
  your patients about how to reduce their risk of overdose.
• Talk to patients who use drugs about naloxone. Provide patients with a prescription for naloxone
  or direct them to where they can access naloxone at no cost.
  o Click here for information and resources related to naloxone.
• Encourage patients to check their drugs.
  o Talk to your patients about FTS. Click here or here for more information on how to get FTS.
  o Recommend that individuals who use drugs connect with drug-checking services. Locations
  and hours of availability are below.
  OnPoint NYC East Harlem (Manhattan): Tues (10:30 AM – 5 PM)
  VOCAL-NY (Brooklyn): Wed (10 AM – 4 PM)
  BOOM!Health (Bronx): Thurs (10 AM – 4 PM)
  Housing Works Cylar House (Manhattan): Thurs (11 AM – 5 PM)
  OnPoint NYC Washington Heights (Manhattan): Fri (10 AM – 4 PM)
  St. Ann’s Corner of Harm Reduction (Bronx): Contact drug.checking@health.ny.gov
  for hours of operation
  For locations outside of NYC, click here
• Familiarize yourself with a local harm reduction organization so you can connect patients
  who may benefit from these services. Click here for a list of NYC’s syringe service
  programs.
• Prescribe medications including methadone or buprenorphine for people with opioid use disorder,
  or facilitate a referral to providers who can prescribe these medications, to prevent overdose.
  o Treatment locators are available here and here.
• Ensure patients who are being treated for an opioid use disorder with methadone or buprenorphine
  maintain uninterrupted access to their medication.
• Patients seeking support to stop using drugs and other resources can call or text 988 or chat at
  nyc.gov/988. Counselors are available 24/7 in more than 200 languages.
  Additional Resources
• New York State Department of Health Issues Public Health Alert for Carfentanil Detected In Drug
  Samples From Central New York
• New York State Department of Health Issues Public Health Alert for Medetomidine Detected In
  Drug Samples In Schenectady and Syracuse
• CFSRE Toxic Adulterant Alert on Medetomidine/Dexmedetomidine
• Medetomidine in Chicago’s Drug Supply
• New York State Office of Addiction Services and Supports Advisory: Another Potent Sedative,
  Medetomidine, Now Appearing in Illicit Drug Supply
• Philadelphia Health Alert on Medetomidine
  Sincerely,
  Rebecca Linn-Walton, PhD, LCSW
  Assistant Commissioner
  Bureau of Alcohol and Drug Use Prevention, Care, and Treatment
  Shivani Mantha, MPH
  Executive Director of Research, Surveillance, Policy, and Communications
  Bureau of Alcohol and Drug Use Prevention, Care, and Treatment

SUMMARY

• Mpox transmission continues to be reported across the state, but case counts remain lower relative to the peak of the 2022 outbreak. In 2024, mpox cases in the United States are higher compared to this time last year. In 2024, mpox diagnoses in New York State have been reported in Albany, Dutchess, Erie, Nassau, Onondaga, Otsego, Putnam, Suffolk, Ulster, and Westchester counties.
• Vaccination among communities disproportionately affected by mpox remains one of our strongest tools at preventing severe illness as well as further transmission.
• Providers should review recently issued evidence-based clinical practice recommendations on how to address mpox prevention, presentation, diagnosis, and treatment in adults on the New York State Department of Health AIDS Institute Clinical
  Guidelines website, along with a convenient pocket guide and slide set. Mpox transmission continues to be reported across the state, but case counts remain lower relative to the peak of the 2022 outbreak. In 2024, mpox diagnoses have been reported in Albany, Dutchess, Erie, Nassau, Onondaga, Otsego, Putnam, Suffolk, Ulster, and Westchester counties. In 2024, mpox cases in the United States are higher compared to this time last year. The communities most affected by mpox, as well as the route of transmission of close personal contact/skin to skin contact with mpox lesions, remain the same. Vaccination among communities disproportionately affected by mpox remains one of our strongest tools at preventing severe illness as well as further transmission. The vaccine has been routinely recommended for the prevention of mpox by the Centers for Disease Control and Prevention (CDC). In addition to being protective against Clade IIb mpox, which is the strain currently circulating in the United States, the JYNNEOS vaccine is also expected to protect against Clade I mpox, a more clinically serious strain which is associated with an outbreak in the Democratic Republic of the Congo. While no cases have been reported in the United States to date, CDC and jurisdictional health departments are taking steps to enhance readiness for responding to Clade I mpox. More information can be found in the December 7, 2023 CDC Health Advisory. As of April 1, 2024, JYNNEOS is available through the commercial market. Requests for vaccines submitted to the New York State Department of Health via mpox@health.ny.gov, which have previously been fulfilled through federally procured supply, will be accepted only in cases where commercially available JYNNEOS vaccine is not available or accessible. CDC has released an updated Vaccine Storage and Handling Toolkit, which includes updates to mpox vaccine storage and handling information.
  For those who do acquire mpox, while there are no approved antiviral treatments currently available, some medications are being studied for their effectiveness in treating mpox, including
  tecovirimat (TPOXX). As of early 2023, the federal government has concluded pre-positioning of tecovirimat (TPOXX), and no pre-positioned supply is currently housed in New York State.
  However, the following avenues remain for healthcare providers to access tecovirimat (TPOXX):
• Study of Tecovirimat for Mpox (STOMP): Treatment of mpox with oral tecovirimat (TPOXX) is available through the Study of Tecovirimat for Human Mpox Virus (STOMP) trial facilitated by the National Institute of Allergy and Infectious Diseases (NIAD). Providers are encouraged to discuss the trial with patients with mpox. Multiple participating study sites are located within New York State. More information is available here.
• Expanded Access Investigational New Drug (EA-IND) Protocol: Providers with patients who are not able to enroll in the STOMP trial, who decline enrollment, or who require intravenous tecovirimat (TPOXX) and meet treatment eligibility under the EA-IND protocol should work in concert with their county health department to request a supply of tecovirimat by contacting the CDC’s Emergency Operations Center (EOC) at (770) 488-7100 or poxvirus@cdc.gov