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American Academy of Emergency Medicine

Fact of the Day - June 2014

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

June 30, 2014

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.

June 29, 2014

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.

June 28, 2014

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.

June 27, 2014

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.

June 26, 2014

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.

June 25, 2014

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.

June 24, 2014

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.

June 23, 2014

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.

June 22, 2014

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.

June 21, 2014

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

June 20, 2014

Primary percutaneous coronary intervention preferable to thrombolysis

Optimise RV preload - Avoid: morphine, diuretics, β-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

June 19, 2014

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.

June 18, 2014

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. Milwaukee, WI.

June 17, 2014

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. Milwaukee, WI.

June 15, 2014

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. Milwaukee, WI.

June 14, 2014

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. Milwaukee, WI.

June 13, 2014

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.

June 12, 2014

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

June 11, 2014

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. JAMA2009;302:2323-2329

June 10, 2014

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. Milwaukee, WI.

June 09, 2014

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. Milwaukee, WI.

June 08, 2014

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. Milwaukee, WI.

June 07, 2014

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. Milwaukee, WI.

June 06, 2014

"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.

June 05, 2014

"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.

June 04, 2014

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.

June 03, 2014

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

June 02, 2014

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

June 01, 2014

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