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American Academy of Emergency Medicine

Fact of the Day - March 2014

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

March 31, 2014

Metabolic state of pyloric stenosis: A late stage finding of pyloric stenosis is hypokalemic, hypochloremic metabolic alkalosis.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

March 30, 2014

"Target” sign on US is classic for intussusception.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

March 29, 2014

Bilious vomiting is a sign of obstruction and should be handled as a surgical emergency in any child less than 1 yr. old. 

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

March 28, 2014

Blood cultures are positive in up to 90% of patients with epiglottitis while cultures from the epiglottis are much less sensitive.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

March 27, 2014

Foreign bodies such as coins will be oriented in the sagittal plane when lodged in the trachea thus appearing as a thick line on an AP CXR.  If in the esophagus the AP CXR will show a round object due to them being in the coronal plane.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013.

March 26, 2014

Asthma exacerbations accounts for 640,000 ER visits a year and are the most frequent reason for pediatric hospitalization.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

March 25, 2014

Nose and vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department. There is no significant difference in time to administration of analgesia between agents, but a learning curve has been identified. Sustained effort should be placed on the use of simple coanalgesia. The clinical performance of intranasal diamorphine compares favorably with intravenous morphine in children with severe pain, and it remains an appropriate preferred agent.

Luke Regan, Andrew R Chapman, Anna Celnik, Lesley Lumsden, Reem Al-Soufi, Nicola P McCullough. Emerg Med J 2013;30:49-52

March 24, 2014

In patients with acute venous thromboembolism, a treatment regimen of fixed-dose oral apixaban was non-inferior to traditional therapy of subcutaneous enoxaparin followed by warfarin.  The apixaban treatment group experienced significantly less bleeding events, as well.

Agnelli, Giancarlo et al. "Oral Apixaban for the Treatment of Acute Venous Thromboembolism." New England Journal of Medicine 369 (2013): 799-808.

March 23, 2014

In patients in status epilepticus, intramuscular midazolam is as effective and as safe as intravenous lorazepam for seizure cessation.

Silbergleit, Robert et al. "Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus." New England Journal of Medicine 366 (2012): 591-600.

March 22, 2014

In patients suffering TIA or minor ischemic stroke, dual anti-platelet therapy (aspirin + clopidogrel) is superior to aspirin alone in reducing subsequent stroke events.  The combination did not cause more major bleeding events than aspirin alone.

Wang, Y et al. "Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack." New England Journal of Medicine 369 (2013): 11-19.

March 21, 2014

Vertebral compression fractures often present with symptoms suggestive of an ileus.  Thus, the differential for a patient on chronic steroids with abdominal pain should include thoracolumbar compression fracture.

Treadwell, EL et al. "Thoracolumbar Compression Fractures Presenting with an Acute Ileus." Journal of the National Medical Association 9.82 (1990): 669-72.

March 20, 2014

Bowel or bladder incontinence during a transient loss of consciousness should not be used to distinguish seizure from syncope.  Orientation immediately after the event according to an eyewitness was the best discriminating factor in one study.

Hoefnagels, W. A. J., G. W. Padberg, J. Overweg, E. A. Velde, and R. A. C. Roos. "Transient Loss of Consciousness: The Value of the History for Distinguishing Seizure from Syncope." Journal of Neurology 238.1 (1991): 39-43.

March 19, 2014

In evaluation of headache concerning for subarachnoid hemorrhage, head CT performed ≤6 hours from headache onset had sensitivity, specificity, negative predictive value, and positive predictive value of 100% in one study. The authors argue there is thus no value in performing a lumbar puncture in a patient with a sudden onset headache <6 hours prior to completion of a normal head CT.

Backes, D et al. Time-dependent test characteristics of head computed tomography in patients suspected of nontraumatic subarachnoid hemorrhage. Stroke. 2012 Aug; 43 (8): 2115-9.

March 18, 2014

Legg-Calvé-Perthes disease is a syndrome of idiopathic avascular necrosis of the femoral head that presents most frequently in children ages 3-12 years-old.  Radiographic changes are often not present on plain films initially, so a high index of suspicion must remain when evaluating children with lower extremity pain or limp.

Meadows, C., F. Monsell, and A. V. Ramanan. "Normal X Rays in Perthes Disease." Archives of Disease in Childhood 93.3 (2008): 211.

March 17, 2014

Brugada syndrome is characterized by right bundle branch block, persistent ST-elevation in leads V1-V3, and sudden death in a patient with a structurally normal heart.  It is most common in men of Asian descent with a family history of early cardiac death.

Brugada, Pedro, and Josep Brugada. "Right Bundle Branch Block, Persistent ST Segment Elevation and Sudden Cardiac Death: A Distinct Clinical and Electrocardiographic Syndrome." Journal of the American College of Cardiology 20.6 (1992): 1391-396.

March 16, 2014

Bruxism, a clenching of the jaw and/or grinding of the teeth, in the setting of sympathetic overdrive (tachycardia, mydriasis, hyperthermia, etc) should raise suspicion for an acute bath salts ingestion.

Nordt, S., & Swadron, S. (October 2011). Bath Salts - A new and BAD street drug. EM:RAP Podcast. Podcast retrieved from www.emrap.org

March 15, 2014

Two common indications for thumb splints include phalangeal injury to the first digit and injury of the ulnar collateral ligament.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008.

March 14, 2014

Otitis media is the second most common cause of childhood illness, with peak incidence at age 3-24 months.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008

March 13, 2014

Abdominal pain occurs in 100% of acute appendicitis cases, and usually preceeds the onset of vomiting.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008.

March 12, 2014

Ruptured abdominal aortic aneurysm (AAA) has a wide variety of presentations, including non-specific pain in the back, flank, abdomen, groin or hip which can mimic renal, hepatobiliary, and pancreatic disorders.

Durdu, T, F Yilmaz, BM Sonmez, S Ulgen, Demir, MS Yilmaz, ED Aeslan, and O Hakbilir. An unusual presentation of ruptured abdominal aorta aneurysm. Am J Case Rep. 2013; 14: 267-269.

March 11, 2014

In the adult patient, the recommended daily dose of acetaminophen is 4 g.  Acute toxicity can occur at doses of 7 g in adults and 140 mg/kg in children.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008.

March 10, 2014

Following traumatic injury, any patient with a Glasgow Coma Scale score <9 or documented injury on CT scan should be admitted to the ICU.  Patients GCS <15, with or without injury on CT scan, should be admitted for observation.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008.

March 09, 2014

Pulmonary embolism presents with non-specific findings.  The most common presentations include dyspnea, tachypnea, or pleuritic chest pain.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008.

March 08, 2014

The diagnosis of compartment syndrome should be considered in patients presenting with extremity pain while suffering from trauma, infection or vascular occlusion.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008.

March 07, 2014

Awake orotracheal intubation: In the setting of a difficult airway, the physician can perform laryngoscopy while the patient is sedated but not paralyzed.

Sherman, SC and JM Weber. USMLE Road Map Emergency Medicine. New York: Lange Medical Books/McGraw-Hill; 2008.

March 06, 2014

 US is >90% sensitive for detecting an abdominal aortic aneurysm, which is anything >3.0 cm in diameter.

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.

March 05, 2014

Lacerations that are closed with tissue adhesives should not use topical ointments or creams because they will loosen the adhesive and result in dehiscence.

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.

March 04, 2014

Indications for imaging a puncture wound include; suspicion of fracture, infected wound, wound caused by materials prone to splinter, foreign body sensation.

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.

March 03, 2014

Wounds deeper than 5mm have a higher association with foreign bodies.

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.

March 02, 2014

The anterior translocation of the tibia relative to the femur more than 7mm and is seen with complete rupture of the anterior cruciate ligament.

 

Chiu SS. Then anterior tibial translocation sign. Radiology. 2006; 239 (3): 914-5

March 01, 2014

Diffuse idiopathic skeletal hyperostosis is caused by calcification of ligaments that attach to the spine. Causes stiffness/ pain of the upper back. Treatment is NSAIDs and physical therapy.

www.mayoclinic.com