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American Academy of Emergency Medicine

Fact of the Day - October 2012

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

October 31, 2012

For patients presenting to a non-interventional facility with cardiogenic shock who have had symptoms of ACS of less than 3-hours duration and there is an anticipated delay to revascularization exceeding 90 minutes, current guidelines suggest administration of fibrinolytics followed by emergent transfer.

EMCC/EBMedicine.net, 2011, Volume 1, Number 4

October 30, 2012

The decision to provide sedation and the selection of the specific pharmacologic agents should be individualized for each patient by the emergency physician and should not be otherwise restricted.

Ann Emerg Med. 2011;57:469

October 29, 2012

A randomized, placebo-controlled, double-blinded superiority trial showed no evidence that ondansetron is superior to metoclopramide and promethazine in reducing nausea in ED adults.

American Journal of Emergency Medicine (2011) 29, 247–255

October 28, 2012

Patients with a first-time seizure who have a normal neurologic examination and no known structural abnormality of the brain do not need to be started on antiepileptic drugs in the ED.

Emerg Med Clin N Am 29 (2011) 41–49

October 27, 2012

The finding of an engorged and dilated right ventricle with flattened left chambers is the sonographic pattern identifying acute obstruction of the pulmonary arterial bed as the cause of cardiac arrest.

American Journal of Emergency Medicine (2011) 29, 216–223

October 26, 2012

Initial interpretation of the ECG reported by callers to the poison center is frequently inaccurate. In prospective study of two hundred cases, the misinterpretation was clinically significant or would have resulted in a change in management recommendations in approximately one quarter of all calls.

Ann Emerg Med. 2011;57:122-127

October 25, 2012

In two centers cohort study of ED patients with atrial flutter, patients eligible for rhythm control had a higher success and lower admission rate with electrocardioversion than patients treated with antiarrhythmic medications. Overall, the majority of patients were discharged home. Deaths were typically related to concurrent medical illness rather than atrial flutter.

Ann Emerg Med. 2011;57:564-571

October 24, 2012

The diagnosis of Bacterial Vaginosis can be made using clinical criteria requiring at least 3 of the following: homogeneous vaginal discharge that smoothly covers the vaginal walls, presence of clue cells on microscopic examination, pH of vaginal fluid greater than 4.5, and a fishy odor of vaginal discharge before or after addition of 10% potassium hydroxide (ie, whiff test).

Emerg Med Clin N Am 29 (2011) 587–603

October 23, 2012

Patients receiving therapeutic hypothermia should be cooled as soon as possible. Data from the 2 largest, prospective trials suggest that the window for therapeutic hypothermia is between 2 and 8 hours following ROSC. Patients should be cooled to a target temperature between 32 and 34C.

Emerg Med Clin N Am 30 (2012) 123–140

October 22, 2012

Patients with isolated abdominal trauma, for whom occult abdominal injury is being considered, are at low risk for adverse outcome and may not need abdominal CT scanning if the following are absent: abdominal tenderness, hypotension, altered mental status (Glasgow Coma Scale score <14), costal margin tenderness, abnormal chest radiograph, hematocrit <30% and hematuria.

Ann Emerg Med. 2011;57: 387-404

October 21, 2012

The combination of ultra-low-dose naltrexone and morphine in extremity trauma does not affect the opioid requirements; it, however, lowers the risk of nausea.

American Journal of Emergency Medicine (2012) 30, 75–78

October 20, 2012

Succinylcholine and rocuronium do not appear to inhibit pupillary response in patients undergoing emergency department rapid sequence intubation.

Ann Emerg Med. 2011;57:234-237

October 19, 2012

Compared with procedural sedation with propofol alone, the combination of ketamine and propofol did not reduce the incidence of respiratory depression but resulted in greater provider satisfaction, less propofol administration, and perhaps better sedation quality.

Ann Emerg Med. 2011;57:435-441

October 18, 2012

Approximately 3% of radiographs interpreted by EPs are subsequently given a discrepant interpretation by the radiology attending. The most commonly missed findings included fractures, dislocations, air-space disease, and pulmonary nodules.

American Journal of Emergency Medicine (2011) 29, 18–25

October 17, 2012

For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%).

BMJ 2011;343:d4277

October 16, 2012

Indications For Retrograde Urethrography Before Urinary Catheterization:

  • Gross hematuria
  • Blood at the urethral meatus
  • Inability to urinate
  • Perineal or scrotal swelling and ecchymosis; a classic finding is a perineal "butterfly hematoma"
  • Absent or high-riding, floating, or boggy prostate on digital rectal examination
  • Inability to insert a urethral catheter
  • Unstable pelvic fracture

Pediatric Emergency Medicine Practice, 2010, ebmedicine.net

October 15, 2012

Recommended Basic Diagnostic Tests For Patients With Neutropenic Fever:

  • CBC with differential
  • Basic chemistries
  • Renal and Liver function tests
  • 2 sets of blood cultures : Adults: 20-30 mL total; Children: 1-5 mL total
  • Urinalysis
  • Chest radiograph
  • Other tests as indicated (eg, sputum gram stain and culture)

EBMedicine.net, March 2010

October 14, 2012

Blood cultures are positive in only 10% to 30% of patients with bacterial pneumonia and only in those where bacteremia occurs. Blood cultures are not recommended in patients as part of outpatient management and are infrequently recommended for inpatient management in cases where severe or unusual forms of pneumonia are present.

Pediatric Emergency Medicine Practice, 2011, ebmedicine.net

October 13, 2012

A new right bundle branch block is associated with lower LV ejection fraction, a greater extent of injury (as defined by cardiac biomarkers), and worse short-term and long-term outcomes.

EBMedicine.net , 2011, Volume 1, Number 4

October 12, 2012

Pulse oximetry overestimates ABG-determined SaO2 by a mean of 2.75% in emergency department patients with severe sepsis and septic shock. This overestimation is exacerbated by the presence of hypoxemia. When SaO2 needs to be determined with a high degree of accuracy arterial blood gases are recommended.

BMC Emergency Medicine 2010, 10:9

October 11, 2012

The nature of the foreign bodies ingested varies significantly. Most impactions in adults result from food boluses (38%–59%) followed by bones (16%–18%), dental prostheses (2%–10%), pills (3%), coins (2%), and batteries (1%). In contrast, most impactions in children are a consequence of coin ingestions.

Emerg Med Clin N Am 29 (2011) 273–291

October 10, 2012

Syncope is common in the pediatric population, with 15% to 25% of children and adolescents between the ages of 8 and 18 years experiencing at least 1 syncopal event by adulthood. Syncope appears to be more common in females, with 20% to 50% of females reporting at least 1 syncopal episode by 20 years of age .

Clinical Pediatric Emergency Medicine, Volume 12, Issue 4 (December, 2011)

October 09, 2012

Antibiotic treatment of mild-to-moderate C. Difficile Colitis is generally with oral metronidazole or oral vancomycin. The recommended regimen is 500 mg 3 times daily or 250 mg 4 times daily for 14 days. If oral vancomycin is used, the dosage is 125 mg 4 times daily for 14 days. Intravenous metronidazole may be used if oral therapy cannot be given, but intravenous vancomycin has no clinical effect on C difficile colitis.

Emerg Med Clin N Am 29 (2011) 347–368

October 08, 2012

ECMO is typically a temporary means of providing oxygenation, carbon dioxide removal, and hemodynamic support to patients with cardiac or pulmonary failure. In instances of cardiac arrest, this device can buy valuable time for resolution of underlying pathophysiologic problems.

Emerg Med Clin N Am 30 (2012) 179–193

October 07, 2012

Contraindication to placement of IO catheter placement: - Fracture of the same bone - Previous intraosseous needle placement attempt in the same bone - Cellulitis overlying placement site - Osteogenesis imperfecta

Emerg Med Clin N Am 30 (2012) 153–168

October 06, 2012

Sites of IO catheter placement: - Proximal medial tibia - Distal medial tibia - Distal medial femur - Anterolateral proximal humerus

Emerg Med Clin N Am 30 (2012) 153–168

October 05, 2012

Plain abdominal radiography is of limited value and may only increase cost of care and a patient’s total exposure to ionizing radiation. Indications for the use of abdominal radiographs include suspicion for pneumoperitoneum or small bowel obstruction in the setting of limited or delayed availability of CT, localization of an ingested foreign body, and the localization of catheters.

Emerg Med Clin N Am 29 (2011) 175–193

October 04, 2012

Patients with a first-time seizure who have no known structural brain pathology, normal serum glucose and sodium levels, and a normal neurologic examination can be discharged from the ED with appropriate outpatient follow-up.

Emerg Med Clin N Am 29 (2011) 41–49

October 03, 2012

In patients with a low pretest probability for PE, a negative quantitative D-dimer assay result can be used to exclude PE.

Ann Emerg Med. 2011;57:628-652

October 02, 2012

Electrolyte derangements that associated with certain ECG changes: Hyperkalemia: peaked T wave ? wide QRS complex ? loss of P wave ? ventricular tachycardia/ ventricular fibrillation - Hypocalcemia: prolonged QT interval ? ventricular tachycardia / torsades de pointes

EBMedicine.net, March 2010

October 01, 2012

The patient with orbital fractures may present with the classic triad of enophthalmos (recession of the eyeball in the socket), restrictive strabismus (diplopia on upward gaze), and infraorbital numbness (anesthesia below the eye along the infraorbital nerve distribution).

EBMedicine.net, May 2010