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American Academy of Emergency Medicine

Fact of the Day - October 2013

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

October 31, 2013

Elderly patients’ mortality rates associated with rib fractures are twice that of their younger cohort. That mortality rate increases as much as 19% with each additional fracture in the elderly.

Jaber N and Jacquet JM. Rib Fractures and Contusions. Critical Decisions in Emergency Medine. 2013:27(3):12.

October 30, 2013

Silver sulphadiazine was consistently associated with poorer healing outcomes than biosynthetic, silicon-coated and silver dressings whilst hydrogel-treated burns had better healing outcomes than those treated with usual care. (for superficial and partial thickness burns)

Wasiak J, Cleland H, et al. Dressings for superficial and partial thickness burns. The Cochrane Library 2013 Issue 3.

October 29, 2013

1mg epinephrine and 20 IU vasopressin plus 40mg methylprednisolone followed by hydrocortisone (300mg/day taper) may significantly improve probability of >20min ROSC (NNT=5.6) and improved neurological outcomes (NNT=11.4)

Mentzelopoulos S.D., Malachias S. et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013:310(3):270-9.

October 28, 2013

Thirst, poor urine output, progressive tachycardia, tachypnea, hypoxemia, agitation, confusion, a rising hematocrit level, and a lack of improvement in symptoms within the first 48 hours are warning signs of impending severe pancreatitis.

David C. Whitcomb, M.D., Ph.D. Acute Pancreatitis. N Engl J Med 2006; 354:2142-2150, doi: 10.1056/NEJMcp054958

October 27, 2013

Approximately 60% of patients with serotonin syndrome present within six hours after initial use of medication, overdose, or change in dosing regimen.

Mason PJ, Morris VA, Balcezak TJ. Serotonin syndrome: presentation of 2 cases and review of the literature. Medicine (Baltimore) 2000;79:201-209

October 26, 2013

The only immunomodulatory therapy that is currently recommended for refractory septic shock is a short course of hydrocortisone.

Derek C. Angus, M.D., M.P.H., and Tom van der Poll, M.D., Ph.D Severe Sepsis and Septic Shock N Engl J Med 2013; 369:840-851

October 25, 2013

Bedside thoracic US was found to be a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma.

Gentry Wilkerson, R. and Stone, M. B. (2010), Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Academic Emergency Medicine, 17: 11–17. doi: 10.1111/j.1553-2712.2009.00628.x

October 24, 2013

A Cochrane review demonstrated significant reductions in the rates of infection with natibiotic prophylaxis only after bites to the hands (odds ratio, 0.10; 95% confidence interval [CI], 0.01 to 0.86) and human bites (odds ratio, 0.02; 95% CI, 0.00 to 0.33)

Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev 2001;2:CD001738-CD001738

October 23, 2013

Among 6326 ventilated ICU patients, hyperoxia (PaO2 > 300 mmHg) had a significantly higher in-hospital mortality rate when compared with normoxia (PaO2 60-300 mmHg) and hypoxia (PaO2 < 60 mmHg), (63% vs. 45% and 57%, respectively).

Kilgannon JH, Jones AE, Shapiro NI, et al. Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA. 2010 Jun 2;303(21):2165-71.

October 22, 2013

The Glasgow-Blatchford bleeding score is a clinical prediction tool for patients with suspected upper gastrointestinal bleeding that assigns points based on the value of the serum urea nitrogen, hemoglobin, systolic blood pressure, pulse rate, and presence of melena, syncope, hepatic disease, or congestive heart failure. A score of zero is associated with low risk for requiring endoscopic intervention.

Overton DT. Chapter 78. Upper Gastrointestinal Bleeding. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

October 21, 2013

Delayed onset of symptoms (6 hours or more post-ingestion) in mushroom toxicity generally portends a poor prognosis, and most deaths are associated with ingestion of mushroom species of the genus Amanita.

Brayer AF, Schneider SM, Cevik AA. Chapter 214. Mushroom Poisoning. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

October 20, 2013

Asthma is a common comorbid condition in children with sickle cell disease and may actually increase the risk of developing acute chest syndrome by up to sixfold.

Caboot JB and Allen JL. Pulmonary complications of sickle cell disease in children. Curr Opin Pediatr 2008;20:279-87.

October 19, 2013

Hyperkalemia in infants with congenital adrenal hyperplasia can usually be corrected with administration of normal saline and hydrocortisone alone 25 milligrams). For ECG changes and arrhythmias, intravenous calcium gluconate 10% (1 mL/kg) and sodium bicarbonate (1 mEq/kg) may be administered, though intravenous insulin and glucose should be avoided if possible due to the risk for profound hypoglycemia.

Qureshi N, Al-Mogbil M, Kentab OY. Chapter 137. Hypoglycemia and Metabolic Emergencies in Infants and Children. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

October 18, 2013

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an under-recognized auto-immune neurological disorder caused by antibodies against the NMDA receptors NR1-NR2 and is frequently associated with a teratoma. It is characterized by different phases of symptomatology including an initial flu-like prodrome of fever, headache, and malaise, followed by a phase of psychotic symptoms (which may include hallucinations) and finally followed by a phase of decreased consciousness and autonomic instability. These patients tend to be young and may initially be diagnosed with a primary psychiatric or toxicological condition.

Punja M, Pomerleau AC, Devlin JJ, Morgan BW, Schier JG, and Schwartz D. Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis: an etiology worth considering in the differential diagnosis of delirium. Clin Tox Aug 2013 [Epub ahead of print].

October 17, 2013

In the treatment of acute organophosphate poisoning, tachycardia is not a contraindication to using atropine because tachycardia can occur secondary to bronchospasm or bronchorrhea with hypoxia, which can be reversed with atropine.

Robey III WC, Meggs WJ. Chapter 195. Pesticides. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

October 16, 2013

Dopamine, norepinephrine, and epinephrine should be avoided in the treatment of patients with hydrocarbon inhalant abuse. The myocardium in these patients may be sensitized to endogenous catecholamines, and administration of exogenous catecholamines may precipitate cardiovascular collapse.

Wax PM, Wong SC. Chapter 193. Hydrocarbons and Volatile Substances. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

October 15, 2013

While traditional teaching for calcium channel overdose treatment involves intravenous calcium, glucagon, high-dose insulin, and glucose, a recent single-center study found that patients with diltiazem or verapamil overdose treated with high-dose vasopressors without hyperinsulinemic euglycemic therapy had complete recovery in all but 1 case.

Levine M, Curry SC, Padilla-Jones A, Ruha AM. Critical Care Management of Verapamil and Diltiazem Overdose With a Focus on Vasopressors: A 25-Year Experience at a Single Center, Ann Emerg Med 2013 Sept;62(3):252-58.

October 14, 2013

While there is no universally accepted protocol for emergency department management of the acutely ischemic limb, common practices include administration of unfractionated heparin, aspirin, dependent positioning, analgesia, and protecting the limb from temperature extremes.

Chopra A, Carr D. Chapter 64. Occlusive Arterial Disease. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

October 13, 2013

Patients ingesting substances with viscosities of <60 SUS (e.g., gasoline, kerosene, mineral seal oil, turpentine, and aromatic and halogenated hydrocarbons) are at greater risk for aspiration than are those ingesting substances with viscosities of >100 SUS (e.g., diesel fuel, grease, mineral oil, paraffin wax, and petroleum jelly).

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 12, 2013

The most common symptom of Reversible Cerebral Vasoconstriction Syndrome (RCVS) is an acute “thunderclap” headache (severe headache reaching maximal intensity within one minute), typically in females 20 to 50 years old, and is often the only symptom at presentation.

Tan LH and Flower, O. Reversible Cerebral Vasoconstriction Syndrome: An Important Cause of Acute Severe Headache. Emerg Med Int. 2012 Jan; Vol 2012; 1-8.

October 11, 2013

Signs of shock in children include tachycardia, cool extremities, altered level of consciousness, weak distal pulses, low urine output, and capillary refill time of >3 seconds. If three boluses of crystalloid fluid fail to correct signs of shock, then packed red blood cells should be given using 10 mL/kg boluses.

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 10, 2013

The abrupt cessation of benzodiazepines after long-term use is associated with a withdrawal syndrome similar to that of alcohol withdrawal, including restlessness, tremors, tachycardia, hypertension, and seizures.

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 09, 2013

The pain of aortic dissection (i.e. midline substernal chest pain) is classically described as tearing, ripping, or searing and radiating to the interscapular area of the back.

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 08, 2013

Subdural hematomas occur 10x more frequently in dialysis patients than in the general population. Bilateral subdural hematomas commonly present without focal neurologic deficits and should be considered in the differential diagnosis in ESRD patients with a change in mental status.

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 07, 2013

Congestive Heart Failure most commonly results from HTN, CAD, or valvular defects. Uremic cardiomyopathy, fluid overload, and arteriovenous (AV) fistula are unique causes of CHF in ESRD patients.

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 06, 2013

Risk factors for aortic dissection include atherosclerosis, uncontrolled hypertension, coarcation of the aorta, bicuspid aortic valves, aortic stenosis, Marfan syndrome, Ehlers-Danlos syndrome, and pregnancy.

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 05, 2013

The only contraindication to tetanus toxoid is a history of neurologic or severe systemic reaction after a previous dose

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

October 04, 2013

In infants 0 to 30 days old, the classic signs of meningitis including neck stiffness, headaches, photophobia, and Kernig or Brudzinski signs are not present due to their immature nervous systems. Instead, rely on nonspecific signs such as abrupt onset of fever, accompanied by decreased activity, decreased feeding, irritability, failure to thrive, and sleepiness.

Richard GC, Lepe M. Meningitis in Children: Diagnosis and Treatment for the Emergency Clinician. Clin Ped Emerg Med. 2013 June; Vol 14(2);146-156.

October 03, 2013

Vitamin D is an increasingly recognized mediator of immune function and possible preventative measure in the pathogenesis of sepsis. Glinde et al published a study showing Vitamin D deficiency was associated with higher sepsis severity in ED patients hospitalized for suspected infection.

Glinde AA, Camargo CA Jr, Shapiro NI. Vitamin D Insufficiency and Sepsis in Emergency Department Patients with Suspected Infection. Acad Emerg Med. 2011 May; 18(5):551-554.

October 02, 2013

In a cadaver model of 1,530 sets of comparative laryngoscopies, bimanual laryngoscopy improved the view (as measured by the percentage of glottic opening (POGO)) compared to cricoid pressure, backward-upward-rightward pressure, and no manipulation.

Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal View During Laryngoscopy: A Randomized Trial Comparing Cricoid Pressure, Backward-Upward-Rightward Pressure, and Bimanual Laryngoscopy. Ann Emerg Med 2006 Jun;47(6):548-55.

October 01, 2013

In the US, rhabdomyolysis is most often due to prolonged muscle compression in the intoxicated patient who lays motionless or in the elderly with dementia after a fall. Measurement of CK levels is more sensitive than myoglobin testing for diagnosis.

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Ch 125: Rhabdomyolysis. Philadelphia, PA: Mosby/Elsevier, 2010.