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American Academy of Emergency Medicine

Fact of the Day - February 2013

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

February 28, 2013

In adults, the 2010 American Heart Association (AHA) guidelines recommend administering 1 mg epinephrine intravenously (IV) or intraosseously (IO) every 3 to 5 minutes during ACLS, with 40 units vasopressin as an alternative for either the first or second dose. For children, the recommended dose of epinephrine is 0.01 mg/kg IV/IO.

Crit Care Clin 28 (2012) 189–198

February 27, 2013

Administration of NAC is indicated in patients who present: (1) with acute ingestions and a concentration on the RMN suggesting possible or probable hepatotoxicity, (2) more than 8 hours after an acute ingestion while awaiting serum APAP concentrations, and 3) more than 24 hours post-ingestion with detectable serum APAP concentrations, elevated AST, or evidence of liver dysfunction.

EBMedicine.net, May 2011

February 26, 2013

Common stroke symptoms due to vertebral arterial dissection that have been reported include incoordination (67%),lateral medullary syndrome (27%-65%), vertigo or dizziness (52%-57%), unilateral facial paresthesias (47%), disequilibrium or unsteadiness (42%), vertigo with nystagmus or "cerebellar signs" (25%-33%), isolated hemiparesis or quadraparesis (11%-25%), hemisensory loss (11%-25%), visual field defects (15%), and dysarthria (15%).

Ebmedicine.net , 2012 Vol. 14 (4)

February 25, 2013

Assessment of the Patient’s Pain-The classic PQRST mnemonic for a complete pain history is as follows:

  • P3: positional, palliating, and provoking factors
  • Q: quality
  • R3: region, radiation, referral
  • S: severity
  • T3: temporal factors (time and mode of onset, progression, previous episodes)

Emerg Med Clin N Am 29 (2011) 159–173

February 24, 2013

Among patients with suspected acute coronary syndrome, hsTnI or cTnI determination 3 hours after admission may facilitate early rule-out of AMI. A serial change in hsTnI or cTnI levels from admission (using the 99th percentile diagnostic cutoff value) to 3 hours after admission may facilitate an early diagnosis of AMI.

JAMA 2011 Dec 28; 306:2684

February 23, 2013

The case-fatality rate for cutaneous mucormycosis ranges from 29% to 83%, depending on severity of disease and underlying medical condition of the patient. Early diagnosis, aggressive surgical debridement, and administration of systemic antifungals have been associated with improved outcomes.

Ann Emerg Med. 2012;59: 53-54

February 22, 2013

Patients in the 91% to 95% saturation group after receiving high FiO2 levels are at high risk of critical desaturation during emergency tracheal intubation. Positioning, preoxygenation, and passive oxygenation should be used. For these patients, consideration should be given to using PEEP during pre-oxygenation and while awaiting muscle relaxation, but the risks and benefits of these techniques must be assessed case by case.

Ann Emerg Med. 2012;59:165-175

February 21, 2013

The negative predictive value of resting single photon emission CT (SPECT) sestamibi imaging for ruling out MI is up to 99% , suggesting that myocardial perfusion imaging is valuable in deciding to admit or discharge a patient from the ED. In addition, it can lead to quicker decisions regarding thepresence of acute MI.

American Journal of Emergency Medicine (2011) 29, 91–101

February 20, 2013

For severe asthma, choose initial tidal volumes of 6–8 mL/kg, which are then customized to maintain safe plateau pressures (20–30 cm H2O maintains sufficient but not barotraumatic tidal recruitment).

JEM, Vol. 38:622

February 19, 2013

The CHADS2 score is used to predict the risk of stroke in patients with atrial fibrillation. Scores range from 0 to 6, with higher scores indicating a greater risk of stroke; the categories of congestive heart failure, hypertension, diabetes, and an age of 75 years or older are each assigned 1 point, and the category of prior stroke or transient ischemic attack is assigned 2 points.

EBmedicine.net, January 12, 2012

February 18, 2013

The presence of hypotension (MAP < 65 mm Hg) after initial fluid challenge, elevated lactate ( > 4 mmol/L), clinical evidence of hypoperfusion, or organ failure strongly suggests severe sepsis or septic shock and should lead to rapid institution of intervention, including EGD.

EBMedicine.net, 2011

February 17, 2013

The diagnosis of type 2 DM, as outlined by the American Diabetes Association (ADA), is based on a HbA1c level >=6.5%, or fasting plasma glucose level >=126 mg/dl (7.0 mmol/l), or a 2-hour plasma glucose >=200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test.

NEJM, April 5, 2012

February 16, 2013

The routine administration of antiemetics with intravenous opioids while treating acute pain in the ED is not necessary. Nausea and vomiting are infrequent after opioid use and the potential benefit from prophylactic antiemetics administration is small at best and outweighed by potentially undesirable additive sedation and extrapyramidal side effects.

Emedhome.com, March 2012

February 15, 2013

For patients who present to the ED with potential acute coronary syndrome, severe pain is not related to likelihood of acute myocardial infarction at presentation or death, acute myocardial infarction or revascularization within 30 days.

Ann Emerg Med 2011 Dec 58:501

February 14, 2013

Approximately 5% of cases of cath lab activation by an Emergency Physician result in “unnecessary” activation (i.e., cardiologist did not perform emergency coronary angiography).

Am Heart J, Vol. 160: 995-1003

February 13, 2013

The diagnosis of symptomatic UTI in patients without indwelling urological devices should be considered only when localizing genitourinary signs or symptoms are present.

EBMedicine.net, January 2012

February 12, 2013

In the ED, prompt and aggressive IV administration of normal saline is the most important treatment for patients with symptomatic or severe hypercalcemia.

EBMedicine.net, March 2010

February 11, 2013

Isopropanol is the most commonly abused toxic alcohol because it is inebriating, readily available, and cheap; it is the least toxic in comparison to methanol and ethylene glycol.

EBMedicine.net, 2010, Volume 12, Number 11

February 10, 2013

Echocardiographic findings suggestive of cardiac tamponade include early diastolic collapse of the right ventricle and late diastolic collapse of the right atrium.

EBMedicine.net, 2010

February 09, 2013

Oral contrast is not required in the diagnostic imaging for evaluation of blunt abdominal trauma.

Ann Emerg Med. 2011;57: 387-404

February 08, 2013

Trauma is the leading cause of death in children aged 1 to 14 years. Thoracic trauma is seen in 4% to 6% of children and is often seen in association with multisystem injuries. Cardiac injury occurs in less than 5% of children with thoracic trauma. The associated injuries include pulmonary contusion (51%), rib or clavicle fractures (51%), brain injury (47%), and abdominal injuries (45%).

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

February 07, 2013

Hereditary angioedema (HAE) is characterized by recurrent abrupt episodes of angioedema without urticaria, which most often affect the skin or mucosal tissues of the upper respiratory and GI tracts. HAE results from deficiency or dysfunction of the C1 inhibitor protein.

J Emerg Med 2012, Jan 27

February 06, 2013

A study demonstrated high degree of variation in management approaches for recent-onset atrial fibrillation and flutter patients treated in academic hospital ED’s. Individual hospital site, age, previous cardioversion, and associated heart failure were independent predictors for the use of rhythm control.

Ann Emerg Med. 2011;57:13-21

February 05, 2013

Vasopressin has also been used for GIB, most often for variceal bleeding, but is associated with a significant re-bleeding rate and a high rate of complications, which include hypertension, dysrhythmias, myocardial and peripheral ischemia, and decreased cardiac output.

Emerg Med Clin N Am 29 (2011) 239–252

February 04, 2013

The use of IABP counterpulsation appears to have benefit in shock patients when used in conjunction with thrombolytics these devices can be deployed under fluoroscopy and, therefore, could feasibly be inserted in the ED.

EBMedicine.net, 2011, Volume 1, Number 4

February 03, 2013

Patients with iliofemoral deep venous thrombosis (DVT) who undergo catheter-directed thrombolysis are at lower risk for post-thrombotic syndrome. At 2 years, post-thrombotic syndrome characterized by pain, edema, and skin deterioration was less common with catheter-directed thrombolysis than with anticoagulation alone (41% vs. 56%).

The Lancet, Volume 379, Issue 9810, Pages 31 – 38

February 02, 2013

High-quality chest compressions (100 per minute at a depth of at least 2 in) should be started as soon as possible and continued with minimal interruptions. Defibrillation should be delayed until at least 30 chest compressions have been done. The four C’s of CPR (compressions, cardioversion, cooling, and catheterization) are the only interventions that have been shown to improve long-term outcomes.

Emerg Med Clin N Am 30 (2012) 35–49

February 01, 2013

A patient presenting recurrently with unilateral epistaxis, especially one that does not respond to simple measures or is associated with other nasal symptoms, should prompt raise suspicion for neoplasm.

NEJM, Vol. 360, pg. 784