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American Academy of Emergency Medicine

Fact of the Day - July 2014

Brought to you by the AAEM Resident & Student Association (AAEM/RSA)

July 26, 2014

First line treatment of severe c-diff infections is oral vancomycin. Severe disease is defined as 60 or more years of age, fever of more than 38.3° C, albumin of less than 2.5 mg/dL, or white blood cell count of more than 15,000/μL within 48 hours of admission

Shen et al. "Current Treatment Options for Severe Clostridium difficile-associated Disease".Gastroenterology Hepatology. 2008;4(2):134–139.

July 25, 2014

In children who do not meet all of the classic criteria (most common in children under one years of age), measurement of high ESR and/or CRP levels as well as slight elevations in serum transaminase levels indicate diagnosis of atypical forms of the disease. This is important to note as children with atypical forms of the disease have notoriously higher rates of coronary artery aneurysms if untreated.

Freeman et.al. Kawasaki Disease: Summary of American Heart Association Guidelines. American Family Physician. 2006; 74(7): 1141-1148.

July 24, 2014

This is a rare diagnosis this is often misdiagnosed as Guillan-Barre syndrome. In 2007 there were only 40 reported cases in the medical literature and it only accounts for less than 1% of brain infarctions. The most common presentation of this disorder is a progressive loss of motor function to the point of quadriplegia with associated dysarthria and dysphagia with no loss of sensation

Tokuoka, K et al. “A case of bilateral medullar infarction presenting with “heart appearance sign”. Tokai J Exp Clin Med. 2007; 32 (3): 99-102

July 23, 2014

Cotton Fever is a syndrome associated with IV drug abuse that mimics sepsis and is due to a SIRS response to an endotoxin release by Enterobacter agglomerans which can be found in the cotton filter used to filter drugs such as heroin.

R. Ferguson, C. Feeney, and V. A. Chirurgi, "Enterobacter agglomerans--associated with cotton fever", Archives of Internal Medicine, October 25, 1993, pp. 2381-2382

July 22, 2014

11% of patients exhibit “emotionalism” and 14% “fear dying”. The average duration lasts between 2-8 hours and per diagnostic criteria resolves within 24 hours. The cause of TGA remains unknown about 6% of patients experience a relapse of TGA per year. These patient’s are not at an increased risk for stroke.

Miller, J. W.; Petersen, R; Metter, E; Millikan, C; Yanagihara, T (1987).”Transient global amnesia: Clinical characteristics and prognosis”. Neurology 37 (5): 733–7.

July 21, 2014

Consider using sodium nitroprusside when CHF is secondary to critical aortic stenosis. It improves myocardial performance with minimal side effects and rapid improvement of symptoms.

Khot, UN, Novao, GM, Propovic, ZB et al. Nitroprusside in critically ill patients with left ventricular dysfunction and aortic stenosis. New England Journal of Medicine. 2003; 348: 1756-1763.

July 20, 2014

In a prospective, randomized, single-blinded trial of 48 subjects with simple cutaneous abscesses (largest diameter less than 5 cm), not packing abscesses did not result in any increased morbidity, and patients reported less pain and used fewer pain medications than packed patients.

O'Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3.

July 19, 2014

The systemic inflammatory response syndrome (SIRS) is defined by the presence of two or more of the following criteria: temperature > 38C or < 36C; heart rate > 90 bpm; respiratory rate > 20 rpm or a PaCO2 of < 32 mmHg; and a white blood cell count of > 12,000 cells/uL or < 4000 cells/uL or > 10% bands.

Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definition Conference. Crit Care Med 2003 Apr;31(4):1250-6.

July 18, 2014

In smoke inhalation victims, a serum lactate concentration of 10 mmol/L or greater has been shown to be both sensitive (87%) and specific (94%) for cyanide poisoning, defined by a blood cyanide concentration greater than 40 umol/L. A normal serum lactate in a symptomatic patient should prompt the clinician to consider other diagnoses, such as carbon monoxide poisoning.

Baud FJ, Barriot P, Toffis V, Riou B, Vicaut E, Lecarpentier Y, Bourdon R, Astier A, Bismuth C. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 1991 Dec 19;325(25):1761-6.

July 17, 2014

When venous blood cannot be accessed, intraosseous blood may serve as a reliable alternative, especially for hemoglobin and hematocrit levels and most analytes in a basic chemistry profile. Exceptions are CO2 levels and platelet counts, which may be lower in intraosseous blood, and white blood cell counts, which may appear elevated.

Miller LJ et al. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.

July 16, 2014

McConnell's sign is an echocardiographic finding in patients with acute pulmonary embolism, demonstrating right ventricular free wall hypokinesis with normal apical contractility.

McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996 Aug 15;78(4):469-73.

July 15, 2014

Ultrasonography of the optic nerve sheath diameter is an easy way to detect increased intracranial pressure (ICP). A pooled study of 231 patients showed that ultrasound had a sensitivity of 90% and specificity of 85% for increased ICP with a positive test associated with a 51-fold higher risk of intracranial hypertension.

Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med. 2011 Jul;37(7):1059-68.

July 14, 2014

Rivaroxaban is the first orally active direct factor Xa inhibitor approved as an alternative to warfarin for stroke prophylaxis in nonvalvular atrial fibrillation. Rivaroxaban is 95% protein-bound and cannot be dialyzed. Reversal agents like activated prothrombin complex concentrates and recombinant factor VII are still being investigated.

Pollack CV, Jr. New Oral Anticoagulants in the ED Setting: A Review. Am J Emerg Med. 2012 Nov;30(9):2046-54.

July 13, 2014

All pediatric patients with accidental sulfonylurea exposure should be admitted for observation. The observation time for asymptomatic, euglycemic children should be at least 18 hours, including an overnight fast.

Levine M, et al. Hypoglycemia After Accidental Pediatric Sulfonylurea Ingestions.Pediatric Emergency Care. 2011;27(9):846–849. Lung DD, Olsen KR. Hypoglycemia in Pediatric Sulfonylurea Poisoning: An 8-Year Poison Center retrospective Study. Pediatrics. 2011;127:e1558-e1564.

July 12, 2014

Guillain-Barré syndrome is characterized by progressive weakness, tingling in the extremities, and absence of reflexes. Respiratory failure is common with up to 30% of patients requiring mechanical ventilation during their illness.

Hughes RA, et al. Supportive care for patients with Guillain-Barré syndrome. Arch Neurol. 2005;62(8):1194.

July 11, 2014

The updated 2012 Surviving Sepsis Campaign fluid resuscitation goals specify a central venous pressure of 8-12 mmHg, central venous oxygen saturation >70% (or mixed venous oxygen saturation >65%), mean arterial pressure >65 mmHg, and urine output of at least 0.5 mL/kg/hr.

Dellinger RP, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med. 2013;41(2):580.

July 10, 2014

Patients treated for acute pulmonary embolism are four times as likely to die of recurrent thromboembolism in the next year as patients treated for deep venous thrombosis.

Victor F. Tapson, M.D. Acute Pulmonary Embolism. N Engl J Med 2008; 358:1037-1052

July 09, 2014

Meta-analysis of 13 controlled, contrast medium-induced nephropathy studies representing almost 26,000 patients failed to demonstrate any difference in the incidence of acute kidney injury, dialysis and death between patients receiving contrast medium and the control group

McDonald, J. S., McDonald, R. J., Comin, J., Williamson, E. E., Katzberg, R. W., Murad, H. M., & Kalimes, D. F. (2013). Frequency of acute Kidney injury Following intravenous contrast Medium administration: A Systematic Review and Meta-Analysis. Radiology, 267(1), 119–128.

July 08, 2014

Multi-slice spiral CT (MSCT) can provide useful information for predicting hyovolemic shock in severe multiple-injury patients. An IVC flatness index > 3.02 suggests the presence of hypovolemic shock in severe multiple-injury patients.

Yang Li, MD, et al. The Flatness Index of Inferior Vena Cava is Useful in Predicting Hypovolemic Shock in Severe Multiple-Injury Patients. The Journal of emergency medicine. 12 August 2013.

July 07, 2014

Early use of component therapy of PRBC:FFP:PLT ratios approaching 1:1:1 reduces mortality in patients who require massive transfusion after trauma and is supported by the best available literature.

Munro AR, Ferguson C. BET 1: Blood component therapy in trauma patients requiring massive transfusion. Emerg Med J 2010 27: 53-55.

July 06, 2014

Patients meeting PERC criteria (age <50 years, pulse rate <100/min, SpO2 >94%, no unilateral leg swelling, no haemoptysis, no surgery or trauma within 4 weeks, no prior deep vein thrombosis or PE and no oral hormone use) should not require any further testing (including a D-dimer).

Balwinder Singh, et al. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: A systematic review and meta-analysis. Emerg Med J 2013;30:9 701-706. 4 October 2012.

July 05, 2014

In a simulated model, 2-handed mask-face sealing techniques resulted in higher ventilatory tidal volumes than 1-handed technique. Tidal volumes from 2-handed and modified 2-handed techniques did not differ. Rescuers should perform bag-valve-mask ventilation with 2-handed techniques.

David Otten, MD, et al. Comparison of Bag-Valve-Mask Hand-Sealing Techniques in a Simulated Model. Annals of Emergency Medicine. 12 August 2013.

July 04, 2014

Three to six days of oral antibiotics for children with streptococcal throat infection is a safe treatment with a comparable effect to the standard duration of 10 days of penicillin. However, results must be interpreted with caution in low-income countries where acute rheumatic fever is still a problem.

Altamimi S, Khalil A, et al. The effect of short duration versus standard duration antibiotic therapy for streptococcal throat infection in children. Cochrane Database of Systematic Reviews, 2013

July 03, 2014

In cases of severe TCA toxicity, administration of sodium bicarbonate may be insufficient to correct the cardiac conduction defects. Use of lidocaine or phenytoin, both Vaughan Williams Class IB antiarrhythmic agents, has been reported as an effective adjunctive therapy in cases of severe cardiotoxicity.

Foianini A, Joseph Wiegand T, Benowitz N. What is the role of lidocaine or phenytoin in tricyclic antidepressant-induced cardiotoxicity? Clin Toxicol (Phila). 2010 May;48(4):325-30.

July 02, 2014

The evidence is inadequate to conclude whether lower doses of thrombolytic agents are more effective than higher doses, or whether one agent is better than another, or which route of administration is the best, for acute ischaemic stroke.

Wardlaw JM, Koumellis P, Liu M. Thrombolysis (different doses, routes ofadministration and agents) for acute ischaemic stroke. Cochrane Database SystRev. 2013 May 31;5:CD000514.

July 01, 2014

There are no data to support the widespread practice of using central venous pressure to guide fluid therapy. Meta-analysis asserts this approach to fluid resuscitation should be abandoned.

Paul E. Marik, MD, FCCM; Rodrigo Cavallazzi, MD. Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense? Crit Care Med 2013; 41:1774–1781