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American Academy of Emergency Medicine

Fact of the Day - November 2012

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

November 30, 2012

If an ingestion of methanol or ethylene is suspected, fomepizole (or ethanol) should be administered as soon as possible. Delaying this treatment will increase the risk of end-organ damage and a prolonged ICU stay.

EBMedicine.net, 2010, Volume 12, Number 11

November 29, 2012

Post-cardiac arrest patients with ROSC should have their Hemodynamic set:

  • Maintain euvolemia
  • Urine output: greater than or equal to 0.5 mL/kg/h
  • MAP: greater than or equal to 65 mm Hg
  • ScvO2: greater than or equal to 70%
  • Lactate clearance of greater than 10% at 2-hour intervals until normal
  • Vasopressors and inotropic agents as needed - Consider mechanical assist device (LVAD, IABP)

Emerg Med Clin N Am 30 (2012) 123–140

November 28, 2012

Post-cardiac arrest patients with ROSC should have initial mechanical ventilator settings:

  • Tidal volume: 6 to 8 mL/kg of ideal body weight
  • Respiratory rate: 16 to 18 bpm
  • PEEP: 5 cm H2O
  • Maintain PaCO2: 40 to 45 mm Hg
  • PetCO2: 35 to 40 mm Hg
  • pH 7.3 to 7.4
  • Monitor and maintain plateau pressure less than or equal to 30 cm H2O

Emerg Med Clin N Am 30 (2012) 123–140

November 27, 2012

Post-cardiac arrest patients with ROSC should have Oxygenation set up: - Titrate FiO2 to maintain SpO2 at greater than 94% and PaO2 around 100 mm Hg, - Titrate PEEP to maintain target SpO2.

Emerg Med Clin N Am 30 (2012) 123–140

November 26, 2012

A randomized, double-blind, placebo-controlled study showed that prothrombin complex concentrate immediately and completely reverses the anticoagulant effect of rivaroxaban in healthy subjects but has no influence on the anticoagulant action of dabigatran at the PCC dose used in the study.

Circulation 2011 Oct 4; 124:1573

November 25, 2012

In approximately 45% of patients with a first-time seizure no cause is identified, and less than 10% have a metabolic or toxicologic cause. Other causes of first-time seizures include stroke, tumor, trauma, and infection, including human immunodeficiency virus (HIV).

Emerg Med Clin N Am 29 (2011) 41–49

November 24, 2012

ED crowding is associated with decreased timeliness and effectiveness—but not equity—of care for children with acute asthma.

Ann Emerg Med. 2011;57:191-200

November 23, 2012

In patients with concomitant unstable hemodynamics and unstable pelvic fracture, angioembolization serves as an effective adjunct to hemostasis. Aggressive embolization should be performed even in patients without contrast extravasation in angiography.

American Journal of Emergency Medicine (2012) 30, 207–213

November 22, 2012

A prospective cross-sectional study demonstrated that during overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.

The Journal of Emergency Medicine Volume 42, Issue 1 , Pages 69-73, January 2012

November 21, 2012

Medical malpractice requires that 1) The physician had a duty, 2) The physician breached the duty, 3) There was harm to the patient, and 4) The harm was caused by the physician's breach of duty. Even if all four medical malpractice conditions are met, there are still special legal defenses that have been and can be used in court to exonerate the physician. These defenses include assumption of the risk, Good Samaritan, contributory negligence, comparative fault, sudden emergency, respectable minority, two schools of thought, and clinical innovation.

The Journal of Emergency Medicine Volume 41, Issue 6 , Pages 598-606, December 2011

November 20, 2012

Lower tract sources of GIB have a re-bleeding rate of approximately 10% to 20%, require operative intervention in 10% to 15% of cases, and have a mortality rate of 4%. Chronic LGIB is responsible for 18% to 30% of patients with iron deficiency anemia presenting to the ED.

Emerg Med Clin N Am 29 (2011) 239–252

November 19, 2012

Only 1/150 pts have serious signs and symptoms (high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness and paralysis) while 80% can have no symptoms at all. Mosquitoes are the vector. Treatment is mainly supportive.

Emedhome.com, March 2012

November 18, 2012

A large double-blind, randomized trial showed that that IM midazolam not only was non-inferior but was superior to IV lorazepam, with successful termination of seizures in 73% subjects in the IM-midazolam group vs. 63% in the IV-lorazepam group.

N Engl J Med 2012;366(7):591-600

November 17, 2012

Addition of post-discharge oral secobarbital to a standard ED migraine treatment regimen decreased headache pain at 24 hours after discharge and improved the rate of headache resolutioncompared with placebo.

American Journal of Emergency Medicine (2011) 29, 86–90

November 16, 2012

The presence of cells and flare in the anterior chamber on slit-lamp examination, along with miosis and pain, are diagnostic of anterior uveitis.

EBMedicine.net, May 2010

November 15, 2012

A substantial number of trauma patients return to the ED within 30 days of being discharged, but only a small proportion of these patients required readmission. Re-presentation is associated with being uninsured or underinsured and with lower neighborhood income level.

Ann Emerg Med. 2011;58:431-437

November 14, 2012

A meta-analysis of almost 6000 patients treated with EGDT concluded clear mortality benefit, with a number needed to treat of only 6 for a life saved.

EBMedicine.net, 2011

November 13, 2012

Ischemic stroke may cause symptoms that are associated with no deficits on the NIHSS score.

Ann Emerg Med. 2011;57:42-45

November 12, 2012

Multidetector CTA can be considered as the initial diagnostic study of choice in blunt neck trauma/blunt cerebrovascular injury.

Ebmedicine.net, March 2012, Volume 4, Number 3

November 10, 2012

Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist. The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%).

BMJ 2011;343:d4277

November 09, 2012

Each year, approximately 5% of all patients presenting to the ED are febrile at triage. Infections including pneumonia, UTI, and cellulitis/abscesses are among the most common admitting diagnoses, and approximately 10% overall receive a hospital discharge diagnosis associated with an infectious disease.

EBMedicine.net, January 2012

November 08, 2012

Bradycardia and AV block most often complicate inferior ACS due to the fact that the AV nodal artery is a branch of the right coronary artery. Ischemia also results in enhanced vagal tone.

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

November 07, 2012

Recommended treatments for refractory Status Epilepticus include: - midazolam infusion (0.2 mg/kg bolus then 0.05–2.0 mg/kg/h) - pentobarbital (3–15 mg/kg slow push [with hemodynamic monitoring] followed by infusion 0.5– 10.0 mg/kg/h -propofol 3–5 mg/kg bolus, infusion at 1–15 mg/kg/h)

Emerg Med Clin N Am 29 (2011) 51–64

November 05, 2012

Even when controlling for confounders, patients >75 yrs old are less likely to receive analgesia than middle age patients.

Ebmedicine.net , March 2012

November 04, 2012

The evidence demonstrates that currently available pain scales are focused primarily on the pain intensity at a single point in time, which leads to underestimation of pain experience and undertreatment of painful conditions. Additionally, no data supports the overall improvement in acute pain management in the ED via use of pain scales.

Emedhome.com, March 2012

November 03, 2012

A recent Cochrane Review found no evidence of prophylactic or therapeutic benefit to recombinant factor VIIa to gain hemostasis in its withOUT hemophilia.

EBMedicine.net, 2010

November 02, 2012

Henoch-Schonlein purpura (HSP) is the most common vasculitis of childhood, associated with the classic palpable purpuric rash on the lower extremities. It occurs most frequently between 5 and 15 years of age, with the mean age of about 5 to 6 years, and 90% of patients are less than 10 years old.

Emerg Med Clin N Am 29 (2011) 401–428

November 01, 2012

Overall, CT has a sensitivity of 64% to 94% and specificity of 79% to 95% in the detection of SBO, with an accuracy of 67% to 95%. It provides information regarding the degree of obstruction (low grade vs. high grade), proximal or distal location, and the specific cause of the obstruction.

Emerg Med Clin N Am 29 (2011) 318-346