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American Academy of Emergency Medicine

Fact of the Day - November 2013

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

November 30, 2013

Early use of component therapy of PRBC:FFP:PLT ratios approaching 1:1:1 reduces mortality in patients who require massive transfusion after trauma and is supported by the best available literature.

Munro AR, Ferguson C. BET 1: Blood component therapy in trauma patients requiring massive transfusion. Emerg Med J 2010 27: 53-55.

November 29, 2013

Patients meeting PERC criteria (age <50 years, pulse rate <100/min, SpO2 >94%, no unilateral leg swelling, no haemoptysis, no surgery or trauma within 4 weeks, no prior deep vein thrombosis or PE and no oral hormone use) should not require any further testing (including a D-dimer).

Balwinder Singh, et al. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: A systematic review and meta-analysis. Emerg Med J 2013;30:9 701-706. 4 October 2012.

November 28, 2013

In a simulated model, 2-handed mask-face sealing techniques resulted in higher ventilatory tidal volumes than 1-handed technique. Tidal volumes from 2-handed and modified 2-handed techniques did not differ. Rescuers should perform bag-valve-mask ventilation with 2-handed techniques.

David Otten, MD, et al. Comparison of Bag-Valve-Mask Hand-Sealing Techniques in a Simulated Model. Annals of Emergency Medicine. 12 August 2013.

November 27, 2013

Three to six days of oral antibiotics for children with streptococcal throat infection is a safe treatment with a comparable effect to the standard duration of 10 days of penicillin. However, results must be interpreted with caution in low-income countries where acute rheumatic fever is still a problem.

Altamimi S, Khalil A, et al. The effect of short duration versus standard duration antibiotic therapy for streptococcal throat infection in children. Cochrane Database of Systematic Reviews, 2013

November 26, 2013

In cases of severe TCA toxicity, administration of sodium bicarbonate may be insufficient to correct the cardiac conduction defects. Use of lidocaine or phenytoin, both Vaughan Williams Class IB antiarrhythmic agents, has been reported as an effective adjunctive therapy in cases of severe cardiotoxicity.

Foianini A, Joseph Wiegand T, Benowitz N. What is the role of lidocaine or phenytoin in tricyclic antidepressant-induced cardiotoxicity? Clin Toxicol (Phila). 2010 May;48(4):325-30.

November 25, 2013

The evidence is inadequate to conclude whether lower doses of thrombolytic agents are more effective than higher doses, or whether one agent is better than another, or which route of administration is the best, for acute ischaemic stroke.

Wardlaw JM, Koumellis P, Liu M. Thrombolysis (different doses, routes ofadministration and agents) for acute ischaemic stroke. Cochrane Database SystRev. 2013 May 31;5:CD000514.

November 24, 2013

There are no data to support the widespread practice of using central venous pressure to guide fluid therapy. Meta-analysis asserts this approach to fluid resuscitation should be abandoned.

Paul E. Marik, MD, FCCM; Rodrigo Cavallazzi, MD. Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense? Crit Care Med 2013; 41:1774–1781

November 23, 2013

Level A recommendations: In order to improve functional outcomes, IV tPA should be offered to acute ischemic stroke patients who meet National Institute of Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can be treated within 3 hours after symptom onset

American College of Emergency Physicians; American Academy of Neurology. Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke in the emergency department. Ann Emerg Med. 2013 Feb;61(2):225-43.

November 22, 2013

Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.

Mentzelopoulos SD. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013 Jul 17;310(3):270-9.

November 21, 2013

It is the skin of the castor bean that contains ricin. Whole bean ingestion causes no symptoms. When chewed, castor beans frequently produce severe gastroenteritis with dehydration and shock

Challoner KR, McCarron MM. Castor bean intoxication. Ann Emerg Med 1990; 19:1177.

November 20, 2013

Antimicrobial therapy should be promptly initiated in any patient with suspected Inhalational Anthrax. Three antimicrobial agents have received United States Food and Drug Administration (FDA) approval for the treatment of anthrax, including IA: ciprofloxacin, doxycycline, and penicillin G procaine

Food and Drug Administration. Prescription Drug Products: Doxycycline and penicillin G procaine administration for inhalational anthrax (post-exposure). In: Federal Register, November 2, 2001.

November 19, 2013

Prolonged cardiopulmonary resuscitation (CPR) should be undertaken following electrical injury regardless of the initial rhythm, since most victims are young and good outcomes have been noted even among patients with asystole

Spies C, Trohman RG. Narrative review: Electrocution and life-threatening electrical injuries. Ann Intern Med 2006; 145:531.

November 18, 2013

The degree of external injury cannot be used to determine the extent of internal damage, especially with low-voltage injuries. Patients with cranial burns or leg burns from lightning are at higher risk for death than others struck by lightning, possibly because more current has passed directly through the body

Cooper MA. Lightning injuries: prognostic signs for death. Ann Emerg Med 1980; 9:134.

November 17, 2013

In High Altitude Cerebral Edema, definitive treatment is immediate decent. If immediate descent is not possible, portable hyperbaric therapy and oxygen may be lifesaving

Hackett PH, Roach RC. High altitude medicine. In: Wilderness Medicine, 5th, Auerbach PS (Ed), Mosby, Philadelphia 2007. p.2.

November 16, 2013

Experienced EP sonographers with a small amount of focused additional training in limited bedside echocardiography can assess LVEF accurately in the ED. LVEF correlation of r(2) = 0.712 with 86.1% overall agreement when compared with formal ultrasounds read by a cardiologist.

Randazzo MR, Snoey ER, Levitt MA, Binder K.Accuracy of emergency physician assessment of left ventricular ejection fraction andcentral venous pressure using echocardiography. Acad Emerg Med2003;10(9):973-977.

November 15, 2013

T wave inversion in aVL was found to be the only ECG variable significantly predicting mid segment left anterior descending artery (LAD) lesions (Odds Ratio 2.93)

Farhan HL et al. Diagnostic Value of Electrocardiographic T Wave Inversion in Lead aVL in Diagnosing Coronary Artery Disease in Patients with Chronic Stable Angina. Oman Med J. 2010 April; 25(2): 124–127.

November 14, 2013

Norepinephrine is preferred first line compared to dopamine, as patients in dopamine group had higher mortality. Dopamine also has increased rate of dysrhythmias.

De Backer D, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779

November 13, 2013

Primary percutaneous coronary intervention preferable to thrombolysis: Optimise RV preload - Avoid: morphine, diuretics, beta-blockers, nitrates. Trial of judicious fluid administration in the absence of pulmonary oedema. Reduce RV afterload - Inotropes, pulmonary vasodilators (nitric oxide, prostacycline), intra-aortic balloon pump. Consider dual-chamber temporary pacing.

Kakouros N, Cokkinos DV. Right ventricular myocardial infarction: pathophysiology, diagnosis, and management. Postgrad Med J. 2010 Dec;86(1022):719-28. Epub 2010 Oct 18

November 12, 2013

Biphasic CT scan for the diagnosis of mesenteric ischemia. A sensitivity of 93%, specificity of 100%, and positive and negative predictive values of 100% and 94%

Aschoff AJ et al. Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography. Abdom Imaging. 2009 May-Jun;34(3):345-57.

November 11, 2013

Meckel`s Diverticulum: Rule of 2`s: found in 2% population, 45% of symptomatic patients are <2yo, 2cm wide, 2cm long, 2 feet from ileocecal valve: p/w isolated painless GIB and can cause intussusception

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.

November 10, 2013

Orthopedic injuries of high specificity for non-accidental trauma: Metaphyseal corner fractures (bucket handle), posterior rib, sternum, long bond shaft in non weight-bearing age child

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.

November 09, 2013

Kawasaki`s Disease Criteria: Fever for 5+ days AND 4/5:bilateral non-exudative conjunctivitis, oral mucosa changes, extremity skin changes, polymorphous rash, cervical adenopathy (>1.5cm diameter)

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.

November 08, 2013

CRITOE: capitellum (2y), radial head (4y), internal epicondyle (6y), trochlea (8y), olecranon (10y), external epicondyle (12y)

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.

November 07, 2013

In 2007, the CDC stopped recommending fluoroquinolones for gonorrhea treatment after it found that the prevalence of fluoroquinolone-resistant N gonorrhoeae was higher than 5% among isolates collected throughout the country.

CDC Grand Rounds: The Growing Threat of Multidrug-Resistant Gonorrhea, MMWR, 62(06);103-106.

November 06, 2013

Synthetic cannabinoids have been linked to acute kidney injury with 12 cases identified in 2012.

Acute Kidney Injury Associated with Synthetic Cannabinoid Use-Multiple States, 2012, Morb Mortal Wkly Rep. 2013;62:93-98

November 05, 2013

In a study of 14,000 ICU patients in 75 countries, gram-negative bacteria were isolated in 62% of patients with severe sepsis who had positive cultures, gram-positive bacteria in 47%, and fungi in 19%.

Vincent JL, Rello J, Marshall J, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009;302:2323-2329

November 04, 2013

Cyanotic congenital heart lesions in cardiovascular distress require PGE1. Do not bring the SpO2 to 100% but be prepared to intubate for apnea secondary to PGE1 use.

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.

November 03, 2013

BLUE BABY: cyanotic heart disease with R->L shunt; MOTTLED BABY: outflow tract obstruction with shock; PINK BABY: congestive heart failure with L->R shunt

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.

November 02, 2013

Status Epilepticus: Traditional definition: seizure longer than 30 min OR more than 1 seizure without return of consciousness Trending definition: single seizure longer than 5 minutes OR more than 1 seizure without return of consciousness

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.

November 01, 2013

HUS requires: 1) microangiopathic hemolytic anemia, 2) thrombocytopenia (<50k PLT) and is often complicated by renal failure. Treat hypertension with nifedipine, labetolol, captopril or hydralazine

Sharieff GQ and Kwon KT. Chapter 5: Pediatrics. in Emergency Medicine: A Focused Review of the Core Curriculum.Shofer, ed. 2013. Milwakee, WI.