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American Academy of Emergency Medicine

Fact of the Day - August 2014

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

August 31, 2014

One small but randomized and multicenter trial examined the use of vasopressin and methylprednisone alongside the usual doses of epinephrine in code situations and showed significantly increased ROSC and survival to hospital discharge in patients assigned to the experimental group.

Mentzelopoulos, et al.(2013). Vasopressin, steroids, and epinephrine and neurologically favorable survivial after in-hospital cardiac arrest: A randomized clinical trial. JAMA, 310(3), 270-279.

August 30, 2014

ICU patients who were randomized to receive blood transfusions if hemoglobin became less than 7 had significantly decreased mortality compared to patients with transfusion cut off of 10.

Hebert, et al.(1999). A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. NEJM, 340(6), 409-417.

August 29, 2014

A recent study examining beta blockade in patients with septic shock showed that those who had esmolol infusions titrated to heart rate had significantly improved mortality compared to those receiving standard treatment.

Morelli, et al.(2013). Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: A randomized clinical trial. JAMA, 310(16), 1683-1691.

August 28, 2014

One large Canadian trial showed that patients who were in new onset A-fib of less than 48 hours could be successfully and safely cardioverted and discharged from the emergency department.

Stiell, et al.(2010). Association of the ottawa aggressive protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM, 12(3), 181-191

August 27, 2014

When calculating anion gaps, corrections must be made for albumin by adding 2.5 to the AG for every gram/deciliter of albumin under 4.2.

Rosen, Peter, John A. Marx, and Ron M. Walls. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier/Saunders, 2014. Print.

August 26, 2014

Hypokalemia is seen in over 20% of hospitalized patients and is even more common in those taking thiazide diuretics.

Rosen, Peter, John A. Marx, and Ron M. Walls. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier/Saunders, 2014. Print.

August 25, 2014

If a foreign body is obstructing the bifurcation of the trachea and causing respiratory collapse, intubation can be attempted to pass the obstruction into one mainstem bronchus and thus preserve air flow through the other lung.

Rosen, Peter, John A. Marx, and Ron M. Walls. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier/Saunders, 2014. Print.

August 24, 2014

Adult patients suffering from an acute airway obstruction often resemble those with an MI, with this presentation called a “cafe coronary”.

Rosen, Peter, John A. Marx, and Ron M. Walls. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier/Saunders, 2014. Print.

August 23, 2014

90% of epistaxis can be attributed to anterior nasal bleeding, usually from Kiesselbach's plexus, and will resolve without complication, but posterior bleeding is more difficult to control and may require admission.

Rosen, Peter, John A. Marx, and Ron M. Walls. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier/Saunders, 2014. Print.

August 22, 2014

Any patients at high risk for TB; including HIV-positive patients with cough, patients with hemoptysis, or patients with any TB history presenting with cough or fever, should be placed in respiratory isolation immediately upon presentation to the ED.

Marx JA, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.

August 21, 2014

Pityriasis rosea, a common, self-limited rash, can initially present with a pigmented herald patch, which precedes the smaller lesions that can occur in the characteristic “Christmas Tree” pattern.

Marx JA, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.

August 20, 2014

On average anaphylactic reactions present within 5-30 minutes after parenteral exposure and 2 hours after ingestion, with most deaths occurring within the first 30 minutes. Symptoms can seemingly resolve and return in several hours in biphasic anaphylaxis.

Marx JA, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.

August 19, 2014

ETCO2 corresponds closely with alveolar CO2 in patients with normal cardiopulmonary function, but is inaccurate in patients with PE, cardiac arrest, hypovolemia, obstructive lung disease. It can also be less accurate with patients in the lateral decubitus position.

Marx JA, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.

August 18, 2014

Since the intercostal muscles are innervated by nerves originating in the thoracic spine, an abdominal breathing pattern indicates an injury below the level of C4.

Marx JA, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.

August 17, 2014

CT Abdomen and Free Air: The lung window can be useful to aid in evaluating CT abdomens for free air.

Oxford American Handbook of Radiology edited by Petra J. Lewis, Nancy J. McNulty. 2013, Oxford University Press.

August 16, 2014

From infancy to 6 years, acute presentations of hypertensive crisis include hemolytic uremic syndrome and acute glomerulonephritis; coarctation of the aorta, and renal artery stenosis should also be considered in this early age group.

Patel NH, Romero SK, Kaelber DC. Evaluation and Management of Pediatric Hypertensive Crisis: Hypertensive Urgency and Hypertensive Emergencies. Open Access Emergency Medicine. 2012 Nov; 4:85-92.

August 15, 2014

Acute dystonias are the most common side effect of antipsychotic medications seen in the ED. They can be rapidly corrected by treatment with benztrophine, 1-2mg IV, or diphenhydramine, 25-50mg IV. Dystonias often reoccur despite dosage reduction or discontinuation of offending antipsychotic. Benztropine, 1mg PO two to four times daily, or diphenhydramine, 25mg three times daily, should be continued for 3 days to prevent recurrence.

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

August 14, 2014

In cases of anaphylaxis with respiratory or cardiac arrest, the median time from exposure to arrest is 30 minutes for food, 15 minutes for venom, and 5 minutes for iatrogenic reactions.

Pumphrey RSH. Lessons for Management of Anaphylaxis From a Study of Fatal Reactions. Clin Exp Allergy. 2000; 30:1144-1150

August 13, 2014

In newborn infants, common etiologies of hypertensive urgencies and emergencies include structural lesions such as renal vascular abnormalities, congenital renal and urologic anomalies, and aortic coarctation.

Patel NH, Romero SK, Kaelber DC. Evaluation and Management of Pediatric Hypertensive Crisis: Hypertensive Urgency and Hypertensive Emergencies. Open Access Emergency Medicine. 2012 Nov; 4:85-92.

August 12, 2014

Symptoms of hypervitaminosis A include blurred vision, appetite loss, abnormal skin pigmentation, loss of hair, dry skin, pruritus, long-bone pain, and increased incidence of bone fractures. Massive doses may additionally cause pseudotumor cerebri and hepatic failure.

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

August 11, 2014

Asthma is the most common medical disease in pregnancy and complicates between 3.7% and 8.4% of all pregnancies. There is a small, but significant (15%-20%) increased risk of preterm delivery, low birth weight, and preeclampsia. Management of chronic asthma is the same in pregnant and nonpregnant patients.

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

August 10, 2014

While digoxin toxicity can produce a number of electrocardiographic changes, specific (but not pathognomonic) findings include 1. atrial fibrillation with slow, regular ventricular rate (AV dissociation), 2. nonparoxysmal junctional tachycardia (rate 70-130), 3. atrial tachycardia with block (atrial rate usually 150-200 bpm), 4. bidirectional ventricular tachycardia.

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Chapter 152. Cardiovascular Drugs. Philadelphia, PA; Mosby/Elsevier, 2010.

August 09, 2014

In this article 87% of conjuctivitis seen in children was bacterial - much higher than previous rates. H. influenza and S. pneumoniae were the most common bacterial causes of conjuctivitis. Topical antibiotic treatment can improve remission rates by as much as 6 days.

Patel et al. Clinical Features of Bacterial Conjunctivitis in Children. Academic Emergency Medicine 2007; 14:1-5.

August 08, 2014

Massive transfusion is defined as the transfusion of 10 U PRBCs in 24 hrs. When implementing massive transfusion for a patient with tramatic shock: monitor temperature for hypothermia, monitor fibrinogen levels, and monitor for hypocalcemia and hyperkalemia.

Elmer J, et al. Massive transfusion in traumatic shock. J Emerg Med 2013; 44:829-838.

August 07, 2014

30% of acute ischemic strokes in children are due to varicella. These can be diagnosed if the child had varicella in the previous 12 months, has a unilateral stenosis of a great vessel, and has IgG in CSF. Treatment includes anticoagulation, acyclovir for greater than 7 days, and steroids for 5-10 days.

Simma et al. Therapy in pediatric stroke. Eur J Pediatr. 2103; 172: 867-875.

August 06, 2014

Central venous pressure has been used in the past to assess volume status and fluid responsiveness. In a recent meta-analysis, it was determined there is only a minimal correlation (0.28) between CVP and change in cardiac index. Thus, CVP is not a reliable marker of fluid responsiveness.

Marik PE, Cavallazzi R. 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.

August 05, 2014

When comparing a 5-day course of 40mg prednisone to the standard 14-day course after severe COPD exacerbation, there was no significant reduction of time to next exacerbation and no difference in mortality, incidence of mechanical ventilation, or dyspnea scores.

Leuppi, JD, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA 2013 Jun 5;309(21):2223-31

August 04, 2014

Compared to manual CPR, load-distributing band CPR had a significantly greater odds ratio of ROSC (1.62). Combining both mechanical devices (load-distributing and piston-driven), there is a significant treatment effect compared to manual CPR in favor of higher odds of ROSC (1.53).

Westfall M, Krantz S, Mullin C, Kaufman C. Mechanical versus manual chest compressions in out-of-hospital cardiac arrest. Crit Care Med 2013 Jul; 41(7):1782-9

August 03, 2014

Acetate is metabolized to bicarbonate. The bolus dose should be given as 1-2 mEq/L given over 15-20 minutes. For the maintenance infusion, dilute 150 mEq diluted to 1 L in dextrose 5%, infuse at 2X the maintenance rate. It must be diluted in dextrose 5% and NOT normal saline. If given too rapidly, this treatment can result in hypotension, hypopnea, and myocardial depression.

Neavyn MJ, Boyer EW, Bird SB, Babu KM. "Sodium Acetate as a Replacement for Sodium Bicarbonate in Medical Toxicology: a Review." Published online 30 April 2013. J. Med. Toxicol.

August 02, 2014

Avoid unnecessary CT scan in children > 2 years old with head trauma when: normal mental status, no signs of basilar skull fracture, no LOC, no vomiting, no severe headache, and no severe mechanism (fall < 5 ft, pedestrian struck, rollover MVC).

Kuppermann N, et al. "Pediatric Emergency Care Applied Research Network. Identification of childrent at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study." Lancet 2009 Oct 3;374(9696):1160-70.

August 01, 2014

Mortality rates are up to 3.5 times higher in elderly patients with CDAD compared to younger patients. The strongest risk factor for CDAD in the elderly is antibiotic administration in the previous 6 weeks. Metronidazole is the treatment of choice for uncomplicated infections.

Heppner HJ, et al. "Infections in the Elderly." Crit Care Clin 2013; 29:757-774.