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American Academy of Emergency Medicine

Fact of the Day - March 2016

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

March 31, 2016

During cardiopulmonary resuscitation, increased compression depth has been correlated with an improved short-term survival. Adequate chest compression depth was defined as 1.5 to 2 inches (38-51mm) on the average adult.

Kramer-Johansen J, Myklebust H, Wik L, et al. Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: A prospective interventional study. 71. 2006;3:283-92. PMID: 17070980

March 30, 2016

Adhesions are the most common cause of small bowel obstructions.

Maung A, Johnson D, Piper G, et al. Evaluation and Management of Small Bowel Obstruction: An Eastern Association for the Surgery of Trauma Practice Management Guideline. The Journal of Trauma and Acute Care Surgery. 2012: 73(5 suppl 4):S326-9.

March 29, 2016

Intravenous metoprolol for the treatment of atrial fibrillation with rapid ventricular rate was associated with a higher treatment response in patients considered β-blocker naive compared to patients receiving chronic β-blocker therapy.

Kuang, P. Achieving ventricular rate control using metoprolol in β-blocker-naive patients vs patients on chronic β-blocker therapy. The American Journal of Emergency Medicine. 2015.

March 28, 2016

Intravenous diphenhydramine, when administered as adjuvant therapy with metoclopramide, does not improve migraine outcomes.

Friedman, B., Cabral, L., Adewunmi, V., et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Annals of Emergency Medicine. 2016:67(1)32-39

March 27, 2016

For patients in ventricular fibrillation, 5-second decreases in the pause after compressions have stopped and before defibrillation have been associated with an 86% increase in the chance of shock success. Shock success was defined by termination of ventricular fibrillation.

Edelson DP, Abella BS, Kramer-johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006;71(2):137-45. PMID: 16982127

March 26, 2016

The U.S. Federal Patient Self-Determination Act mandates that the opportunity to sign an advance directive is provided for all patients admitted to a hospital.

Tintinalli, J. E., & Stapczynski, J. S. 17 Ethical Issues of Resuscitation. Tintinalli's emergency medicine: A comprehensive study guide (8th ed.). New York: McGraw-Hill. 2011.

March 25, 2016

Combined Ketamine/Propofol demonstrated a similar side effect profile in regards to cardiorespiratory symptoms versus propofol alone for procedural sedation and analgesia.

Jalili M, Bahreini M, Doosti-Irani A, Masoomi R, Arbab M, Mirfazaelian H. Ketamine-propofol combination (ketofol) vs propofol for procedural sedation and analgesia: systematic review and meta-analysis. Am J Emerg Med. 2015 Dec 29.

March 24, 2016

Patients with a suspected infection in the emergency department who have intermediate lactate level elevations (2.0 to 3.9 mmol/L) carry a moderate to high risk of mortality, even without hypotension.

Puskarich M, A., Illich B. M., Jones A. E. Prognosis of emergency department patients with suspected infection and intermediate lactate levels: a systematic review. J Crit Care. 2014.

March 23, 2016

Patients with hyphema should have head of bed elevated to 30 degrees to promote settling of blood away from visual axis.

Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg 2001; 59:1462.

March 22, 2016

Antibiotics prior to endoscopy or within eight hours of the endoscopy decrease infection rates in cirrhotics with variceal bleeds.

Lee, Y., Tee, H., & Mahadera, S. Role of Prophylactic Antibiotics in Cirrhotic Patients with Variceal Bleeding. World Journal of Gastroenterology. 2014: 20(7), 1790-1796.

March 21, 2016

Patients with suspected acute coronary syndrome with elevated troponin level in the setting of chronic kidney disease have a worse prognosis than patients with normal troponin levels.

Stacy S. R., Suarez-Cuervo C., Berger Z., et al. Role of troponin in patients with chronic kidney disease and suspected acute coronary syndrome. Ann Intern Med. 2014.

March 20, 2016

By combining 4 patterns of ultrasonographic findings, bedside ultrasonography had a higher diagnostic sensitivity and accuracy than CXR in diagnosing CAP confirmed on CT.

Liu X-lei, Lian R, Tao Y-kang, et al. Lung ultrasonography: an effective way to diagnose community-acquired pneumonia. Emerg Med J.2015;32:433-438.

March 19, 2016

Betablockers are contraindicated in patients with cocaine-induced myocardial infactions due to risk of coronary artery spasm.

Kloner RA, Hale S. Unraveling the complex effects of cocaine on the heart. Circulation 1993; 87:1046.

March 18, 2016

Overall, low-quality evidence indicates that corticosteroids reduce mortality among patients with sepsis. Moderate-quality evidence suggests that a long course of low-dose corticosteroids reduced 28-day mortality without inducing major complications and led to an increase in metabolic disorders.

Annane D, Bellissant E, Bollaert PE, et al. Corticosteroids for treating sepsis. Cochrane Database Syst Rev. 2015 Dec 4;12

March 17, 2016

Adjunct IV Diphenhydramine for acute migraine treatment does not improve pain outcomes.

Friedman BW, Cabral L, et al. Dyphenhydramine as adjuvant therapy for acute migrain: An emergency department-based randomized clinical trial. Annals of Emergency Medicine. 2016; 67 (1); 32-39. doi:10.1016/j.annemergmed.2015.07.495

March 16, 2016

Some causes of STEMI without critical coronary artery stenosis may include cocaine, collagen vascular disease, myocarditis, embolism or microvascular disease.

Da Costa A, Isaaz K, Faure E, et al. Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients. Eur Heart J 2001; 22:1459.

March 15, 2016

Length-based pediatric tape in the prehospital setting results in fewer medication dosing errors as well as faster administration times.

Campagne DD, Young M, Wheeler J, Stroh G. Pediatric Tape: Accuracy and Medication Delivery in the National Park Service. West J Emerg Med. 2015 Sep;16(5):665-70.

March 14, 2016

For adult patients with community-acquired pneumonia requiring hospitalization, data suggest that corticosteroid therapy may reduce mortality, need for mechanical ventilation, and hospital length of stay.

Siemieniuk R. A., Meade M. O., Alonso-Coello P., et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015.

March 13, 2016

There is currently insufficient evidence to support mannitol for TBI management.

Gottlieb M, Bailitz J. Does mannitol reduce mortality from traumatic brain injury? Annals of Emergency Medicine. 2016; 67 (1); 83-85. doi:10.1016/j.annemergmed.2015.06.027.

March 12, 2016

In cases of cardiac arrest, mechanical cardiopulmonary resuscitation, in comparison to manual cardiopulmonary resuscitation, has not been demonstrated to significantly improve patient outcomes or survival in large-scale clinical trials.

Prinzing A, Eichhorn S, Deutsch M, Lange R, Krane M. Cardiopulmonary resuscitation using electrically driven devices: a review. J Thorac Dis. 2015;7(10):459-67. 26623121

March 11, 2016

Proximal humerus - palpate the anterior mid-shaft humerus, and continue palpating proximally up the anterior surface of the humerus until the greater tubercle is met. Palpate the coracoid and acromion, then imagine a line between them. The insertion point is about 2cm from its midpoint (not recommended for pediatrics). Proximal tibia: in adults, two fingers' breadths below and medial to the tibial tuberosity. Distal tibia: in adults, two fingers' breadths proximal to the tip of the medial malleolus

http://lifeinthefastlane.com/ccc/intraosseous-needle-insertion/

March 10, 2016

The reported rate of pulmonary toxicity is about 1-2% per patient per year. Pulmonary toxicity usually manifests as an acute or subacute pneumonitis, typically with diffuse infiltrates on chest x-ray or CT. Treatment: discontinue amiodarone and treat with steroids

Wolkove, N. Baltzan, M. Amiodarone pulmonary toxicity. Can Respir J. 2009 Feb; 16(2): 43-48.

March 09, 2016

Systemic glucocorticoids should be given early to improve recovery from acute asthma exacerbations, but may take 6 hours to take effect.

Fanta CH, Rossing TH, McFadden ER Jr. Glucocorticoids in acute asthma. A critical controlled trial. Am J Med 1983; 74:845.

March 08, 2016

Abdominal compartment syndrome occurs when there is organ dysfunction caused by intra-abdominal hypertension (intraabdominal pressures >20-25 mmHg). This can be life-threatening with mortality as high as 60-70%.

Paula, R. Mills, T. Abdominal Compartment Syndrome Treatment and Management. Medscape Updated: Sep 15, 2015

March 07, 2016

Povidone-iodine or chlorhexidine-containing agents suppress bacterial growth on the skin but impair host defenses and promote bacterial growth in the wound itself. Thus, avoid spillage into the wound.

Tintinalli, J. E., & Stapczynski, J. S. 44 Wound Preparation. Tintinalli's emergency medicine: A comprehensive study guide (8th ed.). New York: McGraw-Hill. 2011.

March 06, 2016

EZ-IO placement has a 92-97% first pass success rate, and can manage 5-9 liters of fluid per hour through a single catheter hub. Contraindications: Previous IO attempts in the same bone, previous surgery at the same site (knee replacement, etc.), osteogenesis imperfecta, osteoporosis, infection of the tissue overlying the insertion site, difficulty or inability to locate landmarks, fracture.

http://lifeinthefastlane.com/ccc/intraosseous-needle-insertion/

March 05, 2016

Homemade inhaler spacers, which can be made from cutting a soda or water bottle, are not only easy to make and much more accessible in developing areas, but have been show to be just as effective as conventional spacers in treating children with asthma.

Zar, Brown, Donson. Are spacers made from sealed cold drink bottles as effective as conventional spacers? Western Journal of Medicine, 2000; 173(4): 253

March 04, 2016

For urogenital chlamydia, the efficacy of azithromycin was 97% and the efficacy of doxycycline was 100%, in a closed study population receiving directly observed treatment. Based on pre-specified study characteristics, azithromycin noninferiority could not be established in this study.

Geisler WM, Uniyal A, Lee JY, Lensing SY, Johnson S, Perry RC, Kadrnka CM, Kerndt PR. Azithromycin versus Doxycycline for Urogenital Chlamydia trachomatis Infection. New England Journal of Medicine. 2015 Dec 24;373(26):2512-21. PMID: 26699167

March 03, 2016

RTS,S/AS01 prevented a substantial number of cases of clinical malaria over a 3-4 year period in young infants and children when administered with or without a booster dose. Efficacy was enhanced by the administration of a booster dose in both age categories.

RTS, S. "Efficacy and safety of RTS, S/AS01 malaria vaccine with or without a booster dose in infants and children in Africa: final results of a phase 3, individually randomised, controlled trial." The Lancet (2015).

March 02, 2016

Pyloric stenosis is diagnosed by ultrasound when the channel length is greater than 15mm and the width is greater than or equal to 3mm.

Pandya, S., Heiss, K. Pyloric Stenosis in Pediatric Surgery: An Evidence-Based Review. Surgical Clinics of North America. 2012: 92(3):527-539.

March 01, 2016

During cardiopulmonary resuscitation (CPR), the percentage of chest compressions compliant with standard CPR guidelines may decrease significantly after one minute of continuous compressions. Previous investigations have shown that in the first minute of CPR, 92.9% of compressions met guidelines. In the fifth minute, this percentage dropped to a mere 18%.

Hightower D, Thomas S, Stone C, Dunn K, March J. Decay in quality of closed-chest compressions over time. Ann Emerg Med. 1995;26(3):300-3. PMID: 7661418