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American Academy of Emergency Medicine

Fact of the Day - December 2013

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

December 31, 2013

Characteristic lab findings in isopropyl alcohol toxicity are the presence of ketosis with an osmole gap without a metabolic acidosis.

Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders, 2013. Print.

December 30, 2013

Hypertensive crisis associated with tyramine syndrome can occur minutes to hours after eating foods rich in tyramine or consuming methamphetamines or cocaine.  Additionally, tyramine syndrome can occur up to three weeks after cessation of non-selective monamine oxidase inhibitors.

Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders, 2013. Print.

December 29, 2013

Hypertensive emergency is defined by the presence of blood pressure ≥180/110mmHg and acute target end organ damage. Organs most commonly affected include the brain, heart or kidneys. Headache, epistaxsis and dizziness alone are not evidence of end organ damage.

Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders, 2013. Print.

December 28, 2013

While the classic feature of Henoch-Schonlein purpura is palpable, purpuric or petichial rash in the lower extremities, up to 60% of patients have gastrointestinal manifestations.  The most common gastrointestinal symptom is periumbilical pain secondary to bleeding into the intestinal wall.

Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders, 2013. Print.

December 27, 2013

In the first 30 days of life up to 60% of the cells in normal CSF are polymorphonuclear leucocytes.  Assuming a normal state, after 30 days of life no more than 3 PMNs/mm^3 should be seen in the CSF.

Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders, 2013. Print.

December 26, 2013

A derivative of codeine, desomorphine (street name “Krokodil” and Crocodil”) produces a fast acting opiate-like effect.  Skin and soft tissue injury, including green scaly skin, necrosis and gangrene, occur secondary to the damaging effects of the solvents (red phosphorus, hydrochloric acid, gasoline, paint thinner and ethyl acetate) used to manufacture the drug.

Grund, JP, Latypov A, Harris M. “Breaking Worse: the emergence of Krodile and excessive injuries among people who inject drugs in Eurasia”. International Journal of Drug Policy. Vol 24, 1 Jul 2013.

December 25, 2013

When diagnosing acute mesenteric ischemia, contrast agent enhanced multidetector computed tomography angiography was 93.3% sensitive and 95.9% specific according to a systemic review of 3 prospective and 3 retrospective cohort studies.

Menke J. Diagnostic Accuracy of Multidetector CT in Acute Mesenteric Ischemia: Systematic Review and Meta-Analysis. Radiology July 2010 256:1 93-101.

December 24, 2013

In hypertensive patients with acute aortic dissection the goal blood pressure should be <140/90mmHg in patients without diabetes and <130/80mmHg in patients with diabetes or chronic renal disease.

Hiratzka, Loren F., George L. Bakris, Joshua A. Beckman, Robert M. Bersin, Vincent F. Carr, Donald E. Casey Jr, Kim A. Eagle, Luke K. Hermann, Eric M. Isselbacher, and Ella A. Kazerooni. "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease." Journal of the American College of Cardiology 55.14 (2010): E27-129. Print.

December 23, 2013

In a recent review article, it was suggested that CVP is not a good tool to use to decide fluid responsiveness, as there is no association between the CVP and associated blood volume and instead is simply a marker of right atrial pressure.

Marik, Paul et al. "Does Central Venous Pressure Predict Fluid Responsiveness?: A Systematic Review of the Literature and the Tale of Seven Mares". Chest. 2008; 134(1):172-178

December 22, 2013

Patients with lesions above T6 are at risk for autonomic dysfunction such as hypertension emergency. Common triggers for this dysfunction include bladder distension, bowel impaction, and pressure sores/somatic pain

Krassioukov,A. et al. "Autonomic Dysreflexia in Acute Spinal Cord Injury: An Under-Recognized Clinical Entity". Journal of Neurotrauma. 2003; 20(8):707-716.

December 21, 2013

Studies have shown that in patients with tension pneumothorax, using a 4.5cm catheter in the second intercostal space midclavicular line for decompression as per trauma protocol will not be a long enough needle to adequately penetrate the chest wall in up to 40% of patients.

Zengerink, Immue et al. "Needle Thoracostomy in the Treatment of a Tension Pneumothorax in Trauma Patients: What Size Needle?" Journal of Trauma-Injury Infection & Critical Care. 2008; 64(1):111-114

December 20, 2013

Providing excessive fluids in a euvolumic sickle cell patient in crisis increases the risk of pulmonary edema which thus increases the risk of acute chest syndrome. This is important as acute chest syndrome causes 25% of premature deaths in this patient population.

Platt O. S., Brambilla D. J., Rosse W. F., Milner P. F., Castro O., Steinberg M. H., Klug P. P.Mortality in sickle cell disease: life expectancy and risk factors for early death. N. Engl. J. Med. 1994;330:1639–1644. Second reference: Miller, Scott et al. "Inpatient management of sickle cell pain: A ‘snapshot’ of current practice". American Journal of Hematology. 2012; 87(3):333-336

December 19, 2013

First line treatment of severe c-diff infections is oral vancomycin. Severe disease is defined as 60 or more years of age, fever of more than 38.3° C, albumin of less than 2.5 mg/dL, or white blood cell count of more than 15,000/μL within 48 hours of admission

Shen et al. "Current Treatment Options for Severe Clostridium difficile-associated Disease".Gastroenterology Hepatology. 2008;4(2):134–139.

December 18, 2013

In children who do not meet all of the classic criteria (most common in children under one years of age), measurement of high ESR and/or CRP levels as well as slight elevations in serum transaminase levels indicate diagnosis of atypical forms of the disease. This is important to note as children with atypical forms of the disease have notoriously higher rates of coronary artery aneurysms if untreated.

Freeman et.al. Kawasaki Disease: Summary of American Heart Association Guidelines. American Family Physician. 2006; 74(7): 1141-1148.

December 17, 2013

This is a rare diagnosis this is often misdiagnosed as Guillan-Barre syndrome. In 2007 there were only 40 reported cases in the medical literature and it only accounts for less than 1% of brain infarctions. The most common presentation of this disorder is a progressive loss of motor function to the point of quadriplegia with associated dysarthria and dysphagia with no loss of sensation

Tokuoka, K et al. “A case of bilateral medullar infarction presenting with “heart appearance sign”. Tokai J Exp Clin Med. 2007; 32 (3): 99-102

December 16, 2013

Cotton Fever is a syndrome associated with IV drug abuse that mimics sepsis and is due to a SIRS response to an endotoxin release by Enterobacter agglomerans which can be found in the cotton filter used to filter drugs such as heroin.

R. Ferguson, C. Feeney, and V. A. Chirurgi, "Enterobacter agglomerans--associated with cotton fever", Archives of Internal Medicine, October 25, 1993, pp. 2381-2382

December 15, 2013

11% of patients exhibit “emotionalism” and 14% “fear dying”. The average duration lasts between 2-8 hours and per diagnostic criteria resolves within 24 hours. The cause of TGA remains unknown about 6% of patients experience a relapse of TGA per year. These patient’s are not at an increased risk for stroke.

Miller, J. W.; Petersen, R; Metter, E; Millikan, C; Yanagihara, T (1987).”Transient global amnesia: Clinical characteristics and prognosis”. Neurology 37 (5): 733–7.

December 14, 2013

Consider using sodium nitroprusside when CHF is secondary to critical aortic stenosis. It improves myocardial performance with minimal side effects and rapid improvement of symptoms.

Khot, UN, Novao, GM, Propovic, ZB et al. Nitroprusside in critically ill patients with left ventricular dysfunction and aortic stenosis. New England Journal of Medicine. 2003; 348: 1756-1763.

December 13, 2013

In a prospective, randomized, single-blinded trial of 48 subjects with simple cutaneous abscesses (largest diameter less than 5 cm), not packing abscesses did not result in any increased morbidity, and patients reported less pain and used fewer pain medications than packed patients.

O'Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3.

December 12, 2013

The systemic inflammatory response syndrome (SIRS) is defined by the presence of two or more of the following criteria: temperature >38C or <36C; heart rate >90 bpm; respiratory rate >20 rpm or a PaCO2 of <32mmHg; and a white blood cell count of >12,000 cells/uL or <4000 cells/uL or >10% bands.

Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definition Conference. Crit Care Med 2003 Apr;31(4):1250-6.

December 11, 2013

In smoke inhalation victims, a serum lactate concentration of 10 mmol/L or greater has been shown to be both sensitive (87%) and specific (94%) for cyanide poisoning, defined by a blood cyanide concentration greater than 40 umol/L. A normal serum lactate in a symptomatic patient should prompt the clinician to consider other diagnoses, such as carbon monoxide poisoning.

Baud FJ, Barriot P, Toffis V, Riou B, Vicaut E, Lecarpentier Y, Bourdon R, Astier A, Bismuth C. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 1991 Dec 19;325(25):1761-6.

December 10, 2013

When venous blood cannot be accessed, intraosseous blood may serve as a reliable alternative, especially for hemoglobin and hematocrit levels and most analytes in a basic chemistry profile. Exceptions are CO2 levels and platelet counts, which may be lower in intraosseous blood, and white blood cell counts, which may appear elevated.

Miller LJ et al. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.

December 09, 2013

McConnell`s sign is an echocardiographic finding in patients with acute pulmonary embolism, demonstrating right ventricular free wall hypokinesis with normal apical contractility.

McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996 Aug 15;78(4):469-73.

December 08, 2013

Ultrasonography of the optic nerve sheath diameter is an easy way to detect increased intracranial pressure (ICP). A pooled study of 231 patients showed that ultrasound had a sensitivity of 90% and specificity of 85% for increased ICP with a positive test associated with a 51-fold higher risk of intracranial hypertension.

Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med. 2011 Jul;37(7):1059-68.

December 07, 2013

Rivaroxaban is the first orally active direct factor Xa inhibitor approved as an alternative to warfarin for stroke prophylaxis in nonvalvular atrial fibrillation. Rivaroxaban is 95% protein-bound and cannot be dialyzed. Reversal agents like activated prothrombin complex concentrates and recombinant factor VII are still being investigated.

Pollack CV, Jr. New Oral Anticoagulants in the ED Setting: A Review. Am J Emerg Med. 2012 Nov;30(9):2046-54.

December 06, 2013

All pediatric patients with accidental sulfonylurea exposure should be admitted for observation. The observation time for asymptomatic, euglycemic children should be at least 18 hours, including an overnight fast.

Levine M, et al. Hypoglycemia After Accidental Pediatric Sulfonylurea Ingestions.Pediatric Emergency Care. 2011;27(9):846–849. Lung DD, Olsen KR. Hypoglycemia in Pediatric Sulfonylurea Poisoning: An 8-Year Poison Center retrospective Study. Pediatrics. 2011;127:e1558-e1564.

December 05, 2013

Guillain-Barré syndrome is characterized by progressive weakness, tingling in the extremities, and absence of reflexes. Respiratory failure is common with up to 30% of patients requiring mechanical ventilation during their illness.

Hughes RA, et al. Supportive care for patients with Guillain-Barré syndrome. Arch Neurol. 2005;62(8):1194.

December 04, 2013

The updated 2012 Surviving Sepsis Campaign fluid resuscitation goals specify a central venous pressure of 8-12 mmHg, central venous oxygen saturation >70% (or mixed venous oxygen saturation >65%), mean arterial pressure >65 mmHg, and urine output of at least 0.5 mL/kg/hr.

Dellinger RP, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med. 2013;41(2):580.

December 03, 2013

Patients treated for acute pulmonary embolism are four times as likely to die of recurrent thromboembolism in the next year as patients treated for deep venous thrombosis.

Victor F. Tapson, M.D. Acute Pulmonary Embolism. N Engl J Med 2008; 358:1037-1052

December 02, 2013

Meta-analysis of 13 controlled, contrast medium-induced nephropathy studies representing almost 26,000 patients failed to demonstrate any difference in the incidence of acute kidney injury, dialysis and death between patients receiving contrast medium and the control group

McDonald, J. S., McDonald, R. J., Comin, J., Williamson, E. E., Katzberg, R. W., Murad, H. M., & Kalimes, D. F. (2013). Frequency of acute Kidney injury Following intravenous contrast Medium administration: A Systematic Review and Meta-Analysis. Radiology, 267(1), 119–128.

December 01, 2013

Multi-slice spiral CT (MSCT) can provide useful information for predicting hyovolemic shock in severe multiple-injury patients. An IVC flatness index > 3.02 suggests the presence of hypovolemic shock in severe multiple-injury patients.

Yang Li, MD, et al. The Flatness Index of Inferior Vena Cava is Useful in Predicting Hypovolemic Shock in Severe Multiple-Injury Patients. The Journal of emergency medicine. 12 August 2013.