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American Academy of Emergency Medicine

Fact of the Day - September 2013

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

September 30, 2013

Scombroid poisoning is mediated by a large ingestion of histamine contaminated fish [think tuna, bluefish, and mahi-mahi.] Symptoms range from mild flushing and pruritus to severe disease with cardiovascular and hemodynamic instability. Treatment is symptomatic with H1 and H2 blockers. Use beta agonists and epinephrine for more serious reactions. Remember, this is a histamine reaction, not a seafood allergy!

Bucher JT, Calello DP. A Fish Tale: Flushing and Pruritus after Tuna Ingestion. J of Emerg Med. 2013. 05.49

September 29, 2013

When an eclamptic patient receiving Magnesium in the ED becomes apneic and losses her DTRs, administer 1 gram Calcium gluconate for suspected magnesium toxicity.

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Ch.176:Acute Complications of Pregnancy. Philadelphia, PA; Mosby/Elsevier, 2010.

September 28, 2013

95% of pregnancies within 3 days after missed menses will be detected by a home pregnancy device. A negative result 1 week after missed menses essentially guarantees that a woman is not pregnant.

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Ch.175:General Approach to the Pregnant Patient. Philadelphia, PA; Mosby/Elsevier, 2010.

September 27, 2013

Flourescein evaluation of the cornea under blue light may reveal a bright green stream of fluid (positive Seidel`s test) in a complete corneal laceration.

Cain W Jr, Sinskey RM. Detection of anterior chamber leakage with Seidel's test. Arch Ophthalmol. 1981 Nov;99(11):2013.

September 26, 2013

Using a cutoff of 5 mm, US assessment of Optic Nerve Sheath Diameter is 100% sensitive (95% CI: 83.8-100%) for elevated intracranial pressure.

Qayyum H, Ramlakhan S. Can ocular ultrasound predict intracranial hypertension? A pilot diagnostic accuracy evaluation in a UK emergency department. Eur J Emerg Med. 2013 Apr;20(2):91-7.

September 25, 2013

In pediatric TBI, hyperventilation (PCO2<35mmHg) may be useful for managing an acute rise in ICP or when signs of herniation are present, but should not be used for long periods of time.

Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med. 2012 Jan;13 Suppl 1:S1-82.

September 24, 2013

In a study of 195 pediatric patients, concomitant injuries to other levels in the spine occurred in 32% of patients with an initial identified spinal injury.

Mahan ST, Mooney DP, Karlin LI, et al. Multiple level injuries in pediatric spinal trauma. J Trauma. 2009 Sep;67(3):537-42.

September 23, 2013

When standard treatment (epinephrine, antihistamines, steroids) is unsuccessful in the treatment of ACE Inhibitor-induced angioedema, consider adding FFP.

Hassen GW, Kalantari H, Parraga M, et al. Fresh frozen plasma for progressive and refractory angiotensin-converting enzyme inhibitor-induced angioedema. J Emerg Med. 2013 Apr;44(4):764-72.

September 22, 2013

When prescribing medications out of the ED, remember to warn patients about their side effects. As an example, tetracyclines (especially doxycycline), thiazide diuretics, quinolones, voriconazole, and amiodarone are well known to have phototoxic side effects.

Stern RS. Clinical practice. Exanthematous drug eruptions. N Engl J Med. 2012 Jun 28;366(26):2492-501.

September 21, 2013

While previous approaches to Crotaline snake bites have included cryotherapy (cold water immersion), incision and suction, and electric shock therapy, most of these have proven to be of little benefit or harmful. Current recommendations are only to immobilize the extremity and consider antivenin.

McKinney PE. Out-of-hospital and interhospital management of crotaline snakebite. Ann Emerg Med. 2001 Feb;37(2):168-74.

September 20, 2013

Vancomycin administration is warranted in the context of suspected MRSA infection or when severe systemic illness with a high risk of mortality is present, but incorrect dosing in the ED can result in inefficacy or development of resistance to the drug. The correct dosage is 15-20 mg/kg of body weight.

Fuller, B. M., et al. (2013). "Emergency Department Vancomycin Use: Dosing Practices and Associated Outcomes." The Journal of Emergency Medicine 44(5): 910-918.

September 19, 2013

For up to 2 weeks post-partruition, the immune, respiratory, and cardiovascular changes that occur during pregnancy do not immediately return to baseline and the patient continues to be at an increased risk for complications (including death) from H1NI and seasonal influenza.

Shiber, J. "Post-partum is Also a Risk Factor for Severe H1N1 Disease." The Journal of Emergency Medicine(0).

September 18, 2013

Compartment syndrome as a result crotalinae envenomation is rare and traditionally treated via fasciotomy. However, antivenin administration and supportive care reduced lower-extremity compartment pressures in a 17-month-old following a copperhead (Agkistrodon contortrix) bite.

Mazer-Amirshahi, M., et al. "Elevated Compartment Pressures from Copperhead Envenomation Successfully Treated with Antivenin." The Journal of Emergency Medicine(0).

September 17, 2013

Bezoars are classified based on their contents, with pharmacobezoars resulting from accumulation of long-acting medications and trichobezoars consisting of ingested hair. First-line treatment involves attempts to dissolve the obstruction (e.g. with Coca-Cola) followed by endoscopy or surgery if dissolution is unsuccessful.

Yeh, J., et al. "Bezoar." The Journal of Emergency Medicine(0).

September 16, 2013

Skin dimpling or "puckering" is a rare complication of displaced supracondylar humeral fracture in which the proximal humeral fragment transverses the brachialis muscle and penetrates the overlying dermis. Puckering can be alleviated via axial traction; however, if left untreated, necrosis of the area could result followed by conversion to an open fracture.

Aneja, A., et al. "Skin Dimpling after a Closed Proximal Humerus Fracture." The Journal of Emergency Medicine(0).

September 15, 2013

Characterized by systemic oxidation of deoxyhemoglobin and typically caused by exposure to toxins, methemoglobinemia can also be of congenital origin accompanying a genetic cytochrome b5 reductase deficiency.

Levine, M., et al. "Methemoglobinemia after a Mediastinal Stab Wound." The Journal of Emergency Medicine(0).

September 14, 2013

Due to similar clinical presentations and EKG changes, Takutsubo cardiomyopathy or "broken heart syndrome" can be easily mistaken for acute coronary syndrome and commonly afflicts postmenopausal women and those in acute mental or physical stress.

Ritchie, D., et al. "Takutsubo Cardiomyopathy and Flash Pulmonary Edema In a Trauma Patient." The Journal of Emergency Medicine(0).

September 13, 2013

The SSRI citalopram taken concurrently with levosulpiride (which possesses class III antiarrhythmic properties) can cause severe QT interval prolongation associated with palpitations and syncopal events.

Agosti, S., et al. "Citalopram and levosulpiride: a dangerous drug combination for QT prolongation." The American Journal of Emergency Medicine(0).

September 12, 2013

Administration of sub-cutaneous epinephrine less than 25 minutes after the onset of insect-sting anaphylaxis reverses the hypotension and bronchospam associated with this condition while also decreasing mortality.

Fortenberry, J.E., et al. (1995). "Use of Epinephrine for Anaphylaxis by Emergency Medical Technicians in a Wilderness Setting." Annals of Emergency Medicine 25(6): 785-787.

September 11, 2013

If a child presents with hypertension, edema, proteinuria, and hematuria, consider acute post-streptococcal glomerulonephritis.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 10, 2013

Legg-Calve-Perthes disease is avascular necrosis of the femoral head and commonly occurs in prepubertal children. In contrast, a slipped capital femoral epiphysis commonly occurs in obese pubertal children and may present as knee rather than hip pain.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 09, 2013

Posterior shoulder dislocations are caused by falls, seizures, and electric shocks.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 08, 2013

The scaphoid is the most commonly fractured carpal bone.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 07, 2013

Rhabdomyolysis classically shows urinalysis positive for hemoglobin with no red cells on microscopy and a total CPK more than five times the upper limit of normal. It is treated with a saline infusion initially, supplemented with urine alkalinization, mannitol, and dialysis.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 06, 2013

Osteomyelitis is most commonly caused by Staphylococcus aureus. On the board exam, the following are common associations with causative agents: sickle cell disease and Salmonella, foot puncture wounds and Pseudomonas, and dog/cat bites and Pasteurella.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 05, 2013

Severe hypothermia creates Osborne J waves and dysrhythmias, which generally resolve during rewarming. Atropine, epinephrine, and high-dose dopamine are contraindicated. Defibrillate once if indicated.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 04, 2013

Black widow spider bites cause muscular rigidity that can be mistaken for a surgical abdomen and require treatment with benzodiazepines and antivenin.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 03, 2013

Antivenin is indicated for any coral snake bite and any moderate to severe pit viper bite. Beware of anaphylaxis when horse serum antivenin is used.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 02, 2013

The classic electrolyte abnormalities of adrenal insufficiency are hyponatremia and hyperkalemia.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.

September 01, 2013

The classic triad of myxedema coma is hypotension, hypothermia, and bradycardia.

Schofer JM, Mattu A, Colletti JE, Gray EA, Rogers RL, Shih RD, eds. Emergency Medicine: A Focused Review of the Core Curriculum. Milwaukee, WI: American Academy of Emergency Medicine; 2008.