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American Academy of Emergency Medicine

Fact of the Day - September 2012

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

September 30, 2012

Patients with portal hypertension– related bleeding, which includes esophageal and gastric varices and portal hypertensive gastropathy, have mortality rates of greater than 50% as compared with a 4% rate with bleeding from PUD.

Emerg Med Clin N Am 29 (2011) 239–252

September 29, 2012

A recent meta-analysis of emergency physician ultrasonography as a diagnostic test for ectopic pregnancy found that emergency physician-performed bedside ultrasonography demonstrated a sensitivity of 99.3% (95% CI, 96.6% to 100%) and a negative predictive value of 99.96% (95% CI, 99.6% to 100%) for detecting an intrauterine pregnancy.

EBMedicine.net, 2011

September 28, 2012

Video or optical elements in alternative intubation devices permit looking around the curve of the tongue, without a direct line of sight to the glottic opening. With these devices, laryngeal exposure is generally the simple part of the procedure, and conversely, tube delivery to the glottic opening and advancement into the trachea are sometimes not straightforward.

Ann Emerg Med. 2011;57:240-247

September 27, 2012

When comparing the administration of midazolam by 3 routes to facilitate pediatric laceration repair, the intranasal route demonstrated a greater proportion of patients with optimal activity scores, greater proportions of parents wanting similar sedation in the future, and faster onset but was also the most poorly tolerated at administration. Aerosolized buccal or intranasal midazolam represents an effective and useful alternative to oral midazolam for sedation for laceration repair.

Ann Emerg Med. 2011;58:323-329

September 26, 2012

Victims of penetrating trauma found apneic and pulseless by EMS, based on their patient assessment, should be rapidly assessed for the presence of other signs of life, such as pupillary reflexes, spontaneous movement, or organized ECG activity. If any of these signs are present, the patient should have resuscitation performed and be transported to the nearest ED or trauma center. If these signs of life are absent, resuscitation efforts may be withheld.

EBMedicine.net, November 2009 Volume 1, Number 2

September 25, 2012

Non-alcoholic fatty liver disease is the most common cause of persistently abnormal results on liver chemistry tests; approximately 30% of adults have NAFLD, and its prevalence increases to 70% - 90% among persons who are obese or have diabetes. It is recognized to be an important component of the metabolic syndrome (ie, abdominal obesity, hypertension, dyslipidemia, and diabetes mellitus).

Mayo Clinic Proceedings 2012; 87: 94-97

September 24, 2012

First-line treatment for cerebral toxoplasmosis includes pyrimethamine and sulfadiazine, with folinic acid (leucovorin) to reduce the hematologic adverse effects from the antimicrobial agents. Second-line therapy, in patients who cannot take sulfadiazine or in whom it is not tolerated, is clindamycin, pyrimethamine, and folinic acid.

N Engl J Med 2012;366:745-755

September 23, 2012

CT use in the ED has increased significantly in recent years across a broad range of presenting complaints. The increase has been associated with a decline in admissions or transfers after CT use, although this effect has stabilized more recently.

Ann Emerg Med. 2011;58:452-462

September 22, 2012

The goals of treatment in traumatic hyphema are to prevent repeated eye trauma and re-bleeding, to promote the settling of blood away from the visual axis, and to control anterior uveitis and increases in IOP.

EBMedicine.net, May 2010

September 21, 2012

When evaluating a patient with a migraine in the ED, consider that the new onset or exacerbation of migraine with a new pattern of occurrence, increased severity, or association with focal neurologic symptoms warrants discontinued use of a combined (estrogen plus progestogen) oral contraceptive.

Mayo Clinic Proceedings 2012; 87: 89-93

September 20, 2012

In the case series, the most common signs and symptoms in patients with superior vena cava syndrome were face or neck swelling (82%), upper-extremity swelling (62%), dyspnea at rest(53%), cough (50%), and dilated chest veins (38%).

EBMedicine.net, 2010

September 19, 2012

Treatment with methylene blue should be considered in patients with more than just mild symptoms or with MetHb levels of 20% or greater. Dosing in normal individuals is 1 mg/kg administered intravenously for 5 minutes.

American Journal of Emergency Medicine (2012) 30, 231–235

September 18, 2012

In a retrospective study, emergency physicians with malpractice suits can expect resolution of the case to take over 45 months after an alleged incident, and their malpractice insurer will incur over $14,000 in expenses regardless of the suit outcome. Cases involving patients aged <= 1 year may incur higher indemnity payments.

The Journal of Emergency Medicine Volume 42, Issue 1 , Pages 22-27, January 2012

September 17, 2012

Several scoring systems have been developed in an attempt to assist in the diagnosis of acute appendicitis. The most often cited is the MANTRELS score, which is a mnemonic that uses 8 different variables on a total 10-point scale. These variables include: migration of pain, anorexia, nausea or vomiting, tenderness in the right lower quadrant, rebound tenderness, elevation of temperature, leukocytosis, and leftward shift.

Emerg Med Clin N Am 29 (2011) 347–368

September 16, 2012

The hCG discriminatory level should not be used to determine the management of a hemodynamically stable patient with suspected ectopic pregnancy, if sonography demonstrates no findings of intrauterine or ectopic pregnancy.

J Ultrasound Med 2011 Dec 30:1637

September 15, 2012

In approximately 70% of patients with malignant cord compression, the metastasis is located within the thoracic spine, 20% are located in the lumbo-sacral spine, and 10% in the cervical spine.

EBMedicine.net, 2010

September 14, 2012

Hematochezia due to an upper tract source of bleeding has been associated with a higher transfusion requirement, need for surgery, and mortality rate.

Emerg Med Clin N Am 29 (2011) 239–252

September 13, 2012

Unenhanced CT of the abdomen has excellent sensitivity and specificity for ureterolithiasis, and can point to an alternative diagnosis if no stones are identified.

Emerg Med Clin N Am 29 (2011) 175–193

September 12, 2012

Lidocaine gel administered nasally 5 minutes before NGTI significantly reduces pain and gagging sensations associated with the procedure but is associated with more difficult tube insertion compared to the use of lubricant gel.

American Journal of Emergency Medicine (2011) 29, 386–390

September 11, 2012

The AHA recommends that vasopressin (40 units IV) can be used as an alternate vasopressor therapy for cardiac arrest, indicated in the treatment of adult shock-refractory VF or pulseless VT as one time alternative to epinephrine.

Emerg Med Clin N Am 30 (2012) 65–75

September 10, 2012

Hypercalcemia occurs in approximately 25% of patients with cancer, and approximately half of these patients die within a month after diagnosis.

EBMedicine.net, March 2010

September 09, 2012

Classic signs and symptoms of common STD’s causing genital ulceration: - STD’s Lesion(s): Inguinal Adenopathy, Painful - Genital herpes : Bilateral, painful - Chancroid : Unilateral, painful - Primary syphilis: Bilateral, painless - Lymphogranuloma venereum: Unilateral, painful

Emerg Med Clin N Am 29 (2011) 587–603

September 08, 2012

Open-label, randomized, non-inferiority study that compared outcomes of outpatient and inpatient treatment in consecutive adult patients who presented to 19 emergency departments in Europe and the U.S. with symptomatic PE and risk for death less than 4% (based on the PE Severity Index ) showed that stable low-risk patients with PE could be safely and effectively treated as outpatients with low-molecular-weight heparin.

Lancet 2011 Jul 2; 378:41

September 07, 2012

The implementation of nurses-initiated parenteral opioid analgesia at triage has great potential for timely, efficient and effective pain management in ED's. Despite regulatory and licensing concerns and issue of patients with aberrant drug-related behaviors, the nurse-driven pain protocol at triage should be an integral part of patients care.

Emedhome.com, March 2012

September 06, 2012

When compared with ketamine alone for pediatric orthopedic reductions, the combination of ketamine and propofol produced slightly faster recoveries while also demonstrating less vomiting, higher satisfaction scores, and similar efficacy and airway complications.

Ann Emerg Med. 2011;57:425-433

September 05, 2012

For cellulitis, penicillinase-resistant semisynthetic penicillin or a first-generation cephalosporin should be selected unless streptococci or staphylococci resistance is common in the community.

EBMedicine.net, January 2012

September 04, 2012

Patients with higher Killip class presenting with ACS have worse clinical profile and are less likely to be treated with evidence-based therapy. High Killip class is independent predictors of mortality in ST-elevation myocardial infarction and non–ST-elevation acute coronary syndrome.

American Journal of Emergency Medicine (2012) 30, 97–103

September 03, 2012

Rivaroxaban is an oral anticoagulant that directly and selectively inhibits factor Xa. Factor Xa initiates the final common pathway of the coagulation cascade and results in the formation of thrombin, which catalyzes additional coagulation-related reactions and promotes platelet activation.

N. Engl J Med 2012; 366;9-19

September 02, 2012

Cerebellar ataxia is characterized by an incoordination of movement and unsteadiness due to cerebellar dysfunction. Clinical examination reveals a gait disorder with imbalance, staggering, and difficulties with tandem walking, upper-limb and lower-limb dysmetria, dysdiadochokinesia (difficulty performing rapidly alternating movements), hypotonia, cerebellar dysarthria, and saccadic ocular pursuit.

N Engl J Med 2012;366:636-646

September 01, 2012

In acute upper gastrointestinal bleeding, administration of intravenous erythromycin provides satisfactory endoscopic conditions, without the need for a nasogastric tube and gastric lavage.

Ann Emerg Med. 2011;57:582-589