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American Academy of Emergency Medicine

Fact of the Day - December 2012

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

December 31, 2012

In ED patients with symptomatic atrial fibrillation, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and B-blocker treatment were associated with an increased risk of a 30-day adverse event.

Ann Emerg Med. 2011;57:1-12

December 30, 2012

A prospective, randomized trial comparing 355 acutely ill patients who received etomidate (0.3 mg/kg) or ketamine (2 mg/kg) for intubation demonstrated statistically significant higher rates of adrenal sufficiency in patients receiving etomidate but did not demonstrate overall differences in peak Sequential Organ Failure Assessment (SOFA) score or mortality.

EBMedicine.net, 2011

December 29, 2012

Effective treatment of abscesses entails incision, thorough evacuation of the pus, and probing the cavity to break up loculations. Gram stain, culture, and systemic antibiotics are rarely indicated unless there is extensive surrounding cellulitis, fever, multiple lesions, severely impaired host defenses, or cutaneous gangrene.

EBMedicine.net, January 2012

December 28, 2012

A cohort study of Cardiac-related chest pain in pediatric patients showed that arrhythmia was the most common cardiac-related etiology and an electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain.

American Journal of Emergency Medicine (2011) 29, 632–638

December 27, 2012

One milliliter of FFP per kg generally increases the levels of coagulation factors by 1 to 2 IU/dL, or about 2.5% per unit of FFP. Using this estimation and the example of a 70-kg patient with an INR of 6.0, 14 units (3000 mL) would be needed to replete factor levels to 35% of normal, corresponding to an INR of 1.5.

Emedhome.com, February 2012

December 26, 2012

When given for acute ischemic stroke within 3 hours of symptom onset, recombinant tissue plasminogen activator increases the likelihood of long-term improved functional capacity without an adverse effect on survival. However, there is an increased short-term risk of symptomatic and fatal intracranial hemorrhage.

Ann Emerg Med. 2011;57: e16-e17

December 25, 2012

About 15% of strokes are attributable to documented atrial fibrillation, and 50 to 60% to documented cerebrovascular disease, but in about 25% of patients who have ischemic strokes, no etiologic factor is identified. Subclinical atrial fibrillation is often suspected to be the cause of stroke in these patients.

N Engl J Med 2012;366:120-129

December 24, 2012

Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the door-in to door-out time rarely met the recommended 30 minutes. Nationally, the median door-in to door-out time is more than double the recommended time.

Arch Intern Med 2011 Nov 28; 171:1879

December 23, 2012

Clinically stable patients with isolated blunt abdominal trauma can be safely discharged after a negative result for abdominal CT with IV contrast (with or without oral contrast).

Ann Emerg Med. 2011;57: 387-404

December 22, 2012

When used at a dose of > 1.2 mg/kg, rocuronium provides intubating conditions identical to those of succinylcholine. Recent literature suggests that in patients at high risk of desaturation, rocuronium may provide a longer duration of safe apnea than succinylcholine.

Ann Emerg Med 2011 Nov 1

December 21, 2012

Performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making and case selection for performing chest radiography in blunt trauma patients based on clinical and surgical findings would be efficacious and resource saving.

American Journal of Emergency Medicine (2012) 30, 1–4

December 20, 2012

In multivariate analysis of children presenting to the ED with fever without the source, increased temperature, being female, and higher median income of the patient's zip code were associated with increased odds of having a CBC and urinalysis ordered. Being 24 to 36 months of age was associated with lower odds of receiving both a CBC and a urinalysis.

Pediatrics 2011, Dec 128:e1368

December 19, 2012

Large double-blind, randomized trial indicates that IM administration of midazolam by EMS is a practical, safe, and effective alternative to the IV route for treating prolonged convulsive seizures in the prehospital setting. There would also appear to be implications for seizing ED patients who do not have immediate IV access available.

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

December 18, 2012

Infection with helicobacter pylori is the most common cause of PUD, with non-steroidal anti-inflammatory drug (NSAID) use coming in second. Aspirin use, history of PUD, smoking, and alcohol use are all risk factors for PUD.

Med Clin North Am 2008;92:491–509

December 17, 2012

A large systematic review of the use of somatostatin analogs for acute esophageal variceal bleeding revealed no significant decrease in mortality but did demonstrate a reduction in bleeding and transfusion requirement. The recommended dose for octreotide is a 50-mg bolus intravenously followed by a continuous infusion of 50 mg per hour.

Emerg Med Clin N Am 29 (2011) 239–25

December 16, 2012

Patterns of injury that should raise concerns about maltreatment include bilateral upper or lower extremity burns (stocking or glove distribution), burns isolated to the buttocks or genitalia, burns with a recognizable shape (eg, of an iron or cigarette butt), or burns reportedly caused by a liquid that do not have associated splash marks.

Pediatric Emergency Medicine Practice, 2011, ebmedicine.net

December 15, 2012

Pancreatic necrosis is an important complication of pancreatitis. It carries a mortality of approximately 30% and is responsible for 50% of all deaths from pancreatitis. Necrosis is diagnosed on CT by decreased enhancement of the pancreas, and may require percutaneous drainage or laparotomy.

Emerg Med Clin N Am 29 (2011) 293–317

December 14, 2012

Peribronchial thickening, diffuse interstitial infiltrates, and hyperinflation tend to be seen with viral pneumonia whereas lobar infiltrates, particularly with pneumatoceles and pulmonary abscesses, strongly suggest bacterial pneumonia.

Pediatric Emergency Medicine Practice, 2011, ebmedicine.net

December 13, 2012

According to the available evidence, it would be within the standard of care to discharge home stable patients with recent-onset atrial fibrillation after cardioversion in the ED with adequate follow-up. It should be noted that the return visit rate for relapsed atrial fibrillation is 3% to 17%, and patients should be made aware of this possibility.

Ann Emerg Med. 2011;58:517-520

December 12, 2012

The recommended dose of glucagon for patient with severe cardiovascular instability associated with Beta-blocker toxicity is a bolus of 3 to 10 mg, administered slowly over 3 to 5 minutes, followed by an infusion of 3 to 5 mg/h (0.05 to 0.15 mg/kg followed by an infusion of 0.05 to 0.10 mg/kg/hr).

Circulation. 2010;122:S829-S861

December 11, 2012

DOPE pneumonic for intubated patients who deteriorate: Displacement of the tube Obstruction of the tube Pneumothorax Equipment failure

Emerg Med Clin N Am 30 (2012) 153–168

December 10, 2012

Diagnostic Criteria for Sepsis:
Documented or suspected infection and some of the following:

  • Hyperthermia (temperature > 38.3°C [100.4ºF])
  • Hypothermia (temperature < 36°C [96.8ºF])
  • Tachycardia (heart rate > 90/ minute)
  • Tachypnea (respiratory rate > 20/ minute)
  • Acutely altered mental status
  • Hyperglycemia (glucose > 120 mg/dL) in the absence of diabetes
  • Significant edema (> 20 mL/ kg positive fluid balance in 24 hours)

EBMedicine.net, 2011

December 09, 2012

Complications Of Renal Trauma: • Urine extravasation • Urinoma • Infected urinoma • Secondary hemorrhage • Perinephric abscess • Pseudoaneurysm • Renovascular hypertension • Arteriovenous fistula • Pulmonary complications • Pseudocyst• Chronic pyelonephritis • Chronic calculi • Hydronephrosis • Acute tubular necrosis with renal failure

EBMedicine.net, May 2010

December 08, 2012

Alcohol-related seizures occur 6-48 hrs after the last drink. When multiple seizures occur, the interval between the first and the last seizure is usually less than 6 hrs.

JEM, Vol. 31, pg. 158

December 07, 2012

Inhibitors of steroidogenesis, including ketoconazole and metyrapone can be used to treat symptoms associated with Cushing’s syndrome. Ketoconazole inhibits the first step in cortisol synthesis as well as inhibiting the conversion of 11-deoxycortisol to cortisol. Metyrapone works by blocking the conversion of 11-deoxycortisol to cortisol.

N. Engl J Med 2011; 365;2520-2530

December 06, 2012

Unilateral headache, focal cerebral ischemic symptoms, and partial Horner syndrome is the classic presentation of internal carotid artery dissection.

JEM, Vol. 41, pg. 43

December 05, 2012

The endovascular repair for type B Acute Aortic Dissection is indicated if pain is refractory, BP control is not possible, or complications from the dissection occur (e.g. limb ischemia, extension of dissection, aortic rupture, periaortic leaking, organ malperfusion).

Mayo Clin Proc, Vol. 84, p. 465

December 04, 2012

According to current ACLS guidelines, the immediate step following administration of a shock for VF/Pulseless VT is CPR that should be resumed immediately after shock delivery (without a rhythm or pulse check and beginning with chest compressions) and continue for 2 minutes before the next rhythm check.

Circulation. 2010;122:S729

December 03, 2012

First-line therapy for Status Epilepticus includes lorazepam IV (0.1 mg/kg) or diazepam (0.2 mg/kg); if diazepam is used, it should be immediately followed by a loading dose of phenytoin or fosphenytoin.

Emerg Med Clin N Am 29 (2011) 51–64

December 02, 2012

Hospitalization has been recommended for patients with hyphema who have: re-bleeding, elevated IOP, hyphemas involving more than 50% of the anterior chamber, decreased visual acuity, as well as for noncompliant patients and in suspected cases of child abuse.

EBMedicine.net, May 2011

December 01, 2012

A prominently higher rate of neurologic improvement and favorable clinical outcome was observed among acute ischemic stroke patients 80 years or older treated with IV rtPA or endovascularintervention when compared with non-thrombolytic medical treatment, supporting the use of acute thrombolytic therapies in this patient population when contraindications are not present.

American Journal of Emergency Medicine (2012) 30, 158–164