A case of imported severe plasmodium falciparum malaria in the emergency department and the current role of exchange transfusion treatment.

BACKGROUND: The role of exchange transfusion in the management of severe malaria is not well documented in Emergency Medicine literature. OBJECTIVES: The goal of this article is to review the importance of considering malaria in the differential diagnosis of the febrile returned traveler and to discuss the role of exchange transfusion in the management of severe Plasmodium falciparum malaria. CASE REPORT: A 59-year-old woman presented to the Emergency Department (ED) with severe P. falciparum malaria. Her physical examination was remarkable for scleral icterus, dry mucous membranes, and tachycardia. Her complete blood count revealed a white blood cell count of 6.9 k/uL, with 71% segmented neutrophils, 19% bands, a hemoglobin level of 11.9 g/dL, hematocrit of 37.2%, and a platelet count of 9 k/uL. Hepatorenal impairment was present and malaria parasites with ring form were seen on malaria prep in 18% of red blood cells. The patient was treated with fluids, platelets, quinidine gluconate, doxycycline, and exchange transfusion with significant improvement in the patient's clinical condition. CONCLUSIONS: The high level of parasitemia presenting with acute kidney injury, hyperbilirubinemia, and thrombocytopenia supported the use of exchange transfusion as adjunct therapy. Exchange transfusion was a reasonable consideration in this case and was well tolerated by our patient. Institutions that are equipped with apheresis units should evaluate each case individually in concert with Centers for Disease Control experts and local consultants and weigh the risks and benefits of the use of exchange transfusion as an adjunct in the treatment of severe P. falciparum malaria.

Administrative barriers reduce emergency physician ordering of nasal and acromioclavicular joint radiographs.

The objective of this study was to determine whether administrative barriers to clinician ordering of nasal bone and acromioclavicular (AC) joint radiographs would result in a significant diminution in emergency department use of these films and in patient charges. This study involved a retrospective cohort or pre-post analysis of radiograph ordering by emergency care providers seeing adult patients with nasal area or shoulder injuries. Numbers of films ordered before and after enactment of a restrictive policy change were determined, as well as any charge reductions associated with diminished film use. For each radiograph type, there was a 1-year preintervention period, and 2 subsequent 12-month periods after the policy change. Nasal bone radiographs decreased from 166 in 1994 to 10 in 1995 and 4 in 1996 (P <.001, chi(2)). This resulted in potential annual charge savings of 33,176 dollars. AC joint radiographs decreased from 35 films in 1994 to 5 in 1995 and 8 in 1996 (P <.001, chi(2)), with potential annual charge savings of 6,578 dollars. Adoption of an interdepartmental policy that prohibits physicians from routinely ordering radiographs of limited clinical value can result in significant reduction of radiograph use. This drop in use can lead to considerable reductions in patient charges.