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American Academy of Emergency Medicine

Fact of the Day - November 2015

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

November 30, 2015

In children, ingestion of a single sulfonylurea tablet can cause severe hypoglycemia.

Block BK, Cheung DS, Platts-Mills TF. First Aid for the Emergency Medicine Boards. New York, NY: McGraw-Hill; 2012. Chapter 6 Toxicology.

November 29, 2015

Intramuscular administration of succinylcholine at 4 mg/kg may produce muscle relaxation in a timeframe suitable for rapid sequence intubation.

Shaw, I. et al. What Is the Time to Muscle Relaxation After Intramuscular Administration of Neuromuscular Blockers? Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed.2015.04.013

November 28, 2015

If a seizing patient is refractory to standard benzodiazepine therapy, consider INH toxicity or hyponatremia.

Block BK, Cheung DS, Platts-Mills TF. First Aid for the Emergency Medicine Boards. New York, NY: McGraw-Hill; 2012. Chapter 6 Toxicology.

November 27, 2015

The average rate of expansion of a TAA is 0.10 - 0.42 cm/yr; those > 6cm have a high rate of complications.

Zane RD, Kosowsky, JM, Pocket Emergency Medicine Third Edition. Philadelphia: Wolters Kluwer; 2015: 1-27

November 26, 2015

When an acutely ill infant or child demonstrates bradypnea or an irregular respiratory rate, this often signals impending arrest.

Chameides L, Samson RA, Schexnayder SM, Hazinski MF, eds. Pediatric Advanced Life Support: Provider Manual. First American Heart Association Printing; 2011.

November 25, 2015

Pain described as radiating to the right shoulder has a likelihood ratio of 4.7 for acute MI. Pain described as pressure has a likelihood ratio of 1.3.

Zane RD, Kosowsky, JM, Pocket Emergency Medicine Third Edition. Philadelphia: Wolters Kluwer; 2015: 1-6

November 24, 2015

Apneic oxygenation is associated with a decreased likelihood of desaturation during Rapid Sequence intubation.

Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med. 2015;65(4):371-6.

November 23, 2015

Carbamazepine is structurally similar to TCAs, and thus toxicity will mimic TCA toxicity with CNS and cardiac manifestations.

Block BK, Cheung DS, Platts-Mills TF. First Aid for the Emergency Medicine Boards. New York, NY: McGraw-Hill; 2012. Chapter 6 Toxicology.

November 22, 2015

In patients with acute ischemic stroke, glycoprotein IIb/IIIa inhibitors should be avoided.

Ganti, L. Do Glycoprotein IIb/IIIa Inhibitors Improve Outcomes in Acute Ischemic Stroke? Annals of Emergency Medicine 2015;66 (1): 65-66.

November 21, 2015

In anaphylaxis, intramuscular epinephrine is preferred over subcutaneous regardless of patient age or setting. There is variable and slower absorption with the subcutaneous route.

Amieva-Wang, N. Ewen. "Allergic emergencies." A Practical Guide to Pediatric Emergency Medicine: Caring for Children in the Emergency Department. Cambridge: Cambridge UP, 2010. 52-7. Print.

November 20, 2015

Although HIV patients are at risk for Pneumocystis carinii pneumonia, S. pneumoniae is the most common cause of bacterial pneumonia in this population.

Emerman CL, Anderson E, Cline DM. Emerman C.L., Anderson E, Cline D.M. Emerman, Charles L., et al.Community-Acquired Pneumonia, Aspiration Pneumonia, and Noninfectious Pulmonary Infiltrates. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T Eds. Judith E. Tintinalli, et al.eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=693&Sectionid=45915396. Accessed July 15, 2015.

November 19, 2015

In the critically-ill trauma patient who may benefit from a Massive Transfusion, a confirmed serum pH of <7.35 (high correlation with serum lactate) can serve as a threshold to initiate a Massive Transfusion.

Summersgrill A, Kanter M, Fraser R, Caputo N, Simon R. Determining The Utility Of Metabolic Acidosis For Trauma Patients In The Emergency Department. Special Topics: Critical Care. The Journal of Emergency Medicine, Vol 48, No. 6, pp. 693-698, 2015

November 18, 2015

Intranasal Ketamine 1mg/kg provided similar pain relief compared to intranasal Fentanyl 1µg/kg in children with moderate to severe limb injuries.

Graudins A, Meek R, Egerton-warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015;65(3):248-254.e1.

November 17, 2015

Triage nurse initiated radiography using Ottawa ankle rules led to a statistically significant decrease of 20 minutes in the median ED length of stay at a tertiary care center.

Lee, WW, Filiatrault, L. et al. Effect of Triage Nurse Initiated Radiography Using the Ottawa Ankle Rules on ED Length of Stay at a Tertiary Center, CJEM 2015;1-8. doi: 10.1017/cem.2015.67.

November 16, 2015

In patients with difficult peripheral intravenous access, ultrasound guided peripheral IV lines have a higher success rate compared to external jugular vein lines.

Costantino TG, Kirtz JF, Satz WA. Ultrasound-guided peripheral venous access vs. the external jugular vein as the initial approach to the patient with difficult vascular access. J Emerg Med. 2010 Oct;39(4):462-7.

November 15, 2015

Nitroglycerin use in patients with chest pain and inferior STEMI on computer-interpreted ECG is not associated with a higher rate of hypotension compared to patients with STEMI in other territories.

Robichaud, L, Ross, D., et al. Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction. Prehospital Emergency Care, 2015 May 29.

November 14, 2015

In the subgroup with large stones (5-10mm), tamsulosin did increase passage of ureteral stones and should be considered.

Furyk, JS, Chu, K, Banks, C. et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo- Controlled, Randomized, Multicenter Trial. Annals of Emergency Medicine 2015; 1-10.

November 13, 2015

Compression Only CPR is not recommended in infants and children as hypoxic/asphyxial arrest is the most common cardiac arrest etiology in this population.

Chameides L, Samson RA, Schexnayder SM, Hazinski MF, eds. Pediatric Advanced Life Support: Provider Manual. First American Heart Association Printing; 2011.

November 12, 2015

The presence of a pneumothorax in a mechanically ventilated patient requires tube thoracostomy to avoid tension physiology. Thereafter, ventilator settings should avoid large tidal volumes and limit high peak, plateau and end-expiratory pressures.

Richter T and Ragaller, M. Ventilation in chest trauma. J Emerg Trauma Shock 2011; 4 (2): 251.

November 11, 2015

Ecchymosis on the plantar surface of the mid-foot is a physical exam finding suggestive of an occult lisfranc fracture.

Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Cline, D.M., Cydulka, R.K., & Meckler, G.D. (2010). Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th edition. New York: McGraw Hill, Medical Pub. Division.

November 10, 2015

Fibrinolytic therapy should be given to patients with STEMI within 12 hours of onset of symptoms when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.

Zane RD, Kosowsky, JM, Pocket Emergency Medicine Third Edition. Philadelphia: Wolters Kluwer; 2015: 1-9

November 09, 2015

Patients with legionella pneumonia may have GI symptoms such as abdominal pain, vomiting, and diarrhea. The chest xray often shows a patchy infiltrate.

Emerman CL, Anderson E, Cline DM. Emerman C.L., Anderson E, Cline D.M. Emerman, Charles L., et al.Community-Acquired Pneumonia, Aspiration Pneumonia, and Noninfectious Pulmonary Infiltrates. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T Eds. Judith E. Tintinalli, et al.eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=693&Sectionid=45915396. Accessed July 15, 2015.

November 08, 2015

A bag of ice placed over the upper half of a child's face for 15-20 seconds is an appropriate vagal maneuver for infants and children of all ages.

Chameides L, Samson RA, Schexnayder SM, Hazinski MF, eds. Pediatric Advanced Life Support: Provider Manual. First American Heart Association Printing; 2011.

November 07, 2015

Angioedema associated with ACE inhibitors can occur at any point in therapy, not only during the initial course of treatment. Antihistamines and corticosteroids are not indicated, as the mechanism of inflammation is not IgE mediated.

Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

November 06, 2015

Hyponatremia is the most common electrolyte abnormality in MDMA (ecstasy) intoxication due to marked increase in water intake and drug induced inappropriate secretion of ADH.

Campbell, Garland A GA (08/2008). "The agony of ecstasy: MDMA (3,4-methylenedioxymethamphetamine) and the kidney.".Clinical journal of the American Society of Nephrology (1555-9041), 3 (6), 1852

November 05, 2015

The most common hand infection is a paronychia. Early paronychia can be treated conservatively with warm soaks and oral antibiotics.

Amieva-Wang, N. Ewen. "Hand injury." A Practical Guide to Pediatric Emergency Medicine: Caring for Children in the Emergency Department. Cambridge: Cambridge UP, 2010. 497-506. Print.

November 04, 2015

Rapid MRIs and radiographs resulted in nearly identical outcomes for primary care patients with low back pain.

Jarvik JG, Hollingworth W, Martin, B, Emerson SS, et.al. Rapid Magnetic Resonance Imaging vs Radiographs for patients with low back pain. JAMA 2003, 289(21): 2810-18.

November 03, 2015

Anterior cord syndrome occurs in the setting of hyperflexion of the neck. Central cord syndrome occurs with hyperextension.

Simon RR, Sherman SC. Chapter 9. Cervical Spine Trauma. In: Simon RR, Sherman SC. eds. Emergency Orthopedics, 6e. New York, NY: McGraw-Hill; 2011.

November 02, 2015

Benign early repolarization, pericarditis, left ventricular aneurysm, normal variant "male pattern" and pre-excitation are examples of narrow QRS complex ST elevation mimics.

Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med2003;349:2128-35.

November 01, 2015

The PRESEP score could be a valuable tool for identifying septic patients in the prehospital setting in the case of suspected infection.

Bayer, O. et al. An Early Warning Scoring System to Identify Septic Patients in the Prehospital Setting: The PRESEP Score. Academic Emergency Medicine. July 2015. doi: 10.1111/acem.12707