American Academy of Emergency Medicine

Fact of the Day - August 2012

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

August 31, 2012

The risk of recurrent intussusception after reduction is rare but more likely with non-operative reduction. It has been reported in up to 15% of patients after undergoinghydrostatic reduction and up to 3% after operative reduction. The risk is greatest in the first 24 hours after reduction, and therefore some institutions routinely admit these patients during this time for observation.

Emerg Med Clin N Am 29 (2011) 401–428

August 30, 2012

Clopidogrel as a 600 mg loading dose achieves more rapid and effective platelet inhibition than lower dose regimens. Prasugrel 60 mg offers more immediate platelet inhibition due to a single-step activation process. Prasugrel is associated with fewer thrombotic complications than clopidogrel but at the expense of more bleeding complications (including fatal hemorrhage).

EBMedicine.net, 2011, Volume 1, Number 4

August 29, 2012

Patients with diveticulits who have failed outpatient treatment, who require intravenous analgesia, the elderly or immunocompromised, and those with complications of diverticulitis should be hospitalized. Antibiotic options include intravenous ciprofloxacin and metronidazole, or single-drug regimens of b-lactamase inhibitor combinations such as ampicillin-sulbactam or ticarcillin-clavulanate .

Emerg Med Clin N Am 29 (2011) 347–368

August 28, 2012

Hereditary angioedema (HAE) is characterized by recurrent abrupt episodes of angioedema without urticaria, which most often affect the skin or mucosal tissues of the upper respiratory and GI tracts. HAE results from deficiency or dysfunction of the C1 inhibitor protein. The angioedema of HAE responds poorly or not at all to treatments for allergic angioedema, including epinephrine, antihistamines, and glucocorticoids.

J Emerg Med, 2012 Jan 27

August 27, 2012

Succinylcholine is superior to rocuronium for creating excellent intubating conditions and should be the first-line paralytic agent used for rapid sequence intubations.

Ann Emerg Med. 2011;57:301-302

August 26, 2012

Because no prospective clinical trials have examined the use of atropine in asystole or bradycardic PEA arrest and lower-level clinical studies providing conflicting evidence, the 2010 AHA commented that atropine is unlikely to have a therapeutic benefit in cardiac arrest and was therefore removed from the ACLS algorithm.

Emerg Med Clin N Am 30 (2012) 65–75

August 23, 2012

For emergency clinicians, sonographic findings consistent with an IUP include a yolk sac, fetal pole, or fetal heart activity within the uterus, surrounded by an 8-mm rim of myometrium.

EBMedicine.net, 2011

August 22, 2012

Most episodes of febrile neutropenia occur in patients receiving chemotherapy. For most outpatient chemotherapy, the neutrophil nadir typically occurs 5 to 10 days after the last dose.

Mayo Clin Proc, Vol. 81, pg. 843

August 21, 2012

Twenty milligrams or 40 mg of metoclopramide is no better for acute migraine than 10 mg of metoclopramide.

Ann Emerg Med. 2011;57:475-482

August 20, 2012

Patients presenting with acute rhabodmyolysis often require in the neighborhood of 10 liters of fluid per day, however, administration of large amount of normal saline can contribute to acidosis, due to the dilution of serum bicarbonate with a solution high in chloride ions, generating hyperchloremic metabolic acidosis. Acidosis exacerbates the renal injury associated with rhabdomyolysis.

NEJM, Vol. 361, p. 62

August 19, 2012

Indications for Antidotal Therapy For Methanol Or Ethylene Glycol Toxicity:

  • Serum concentration of methanol or ethylene glycol > 20 mg/dL
  • History or suspicion of methanol or ethylene glycol ingestion and two of the following:
    • Osmolal gap > 10 mOsm
    • Arterial pH < 7.3
    • Serum bicarbonate < 20 mmol/L
    • Presence of urinary oxalate crystals

EBMedicine.net, 2010, Volume 12, Number 11

August 18, 2012

Suggested indications for hospital admission for children with gastroenteritis include: severe dehydration, neurological involvement, toxic state or shock, inability to tolerate oral rehydration, potential for surgery, failure of treatment despite oral rehydration therapy, or uncertain diagnosis.

Emerg Med Clin N Am 29 (2011) 211–237

August 17, 2012

Non-contrast head CT scans reveal abnormalities ranging from 3% to 40% in patients with first-time seizure, which includes two-thirds with focal lesions and one-third with diffuse cerebral atrophy. The incidence of finding an abnormality is increased if the patient has a focal neurologic finding, focal onset of the seizure, history of malignancy, or HIV.

Emerg Med Clin N Am 29 (2011) 41–49

August 16, 2012

Quantitative and qualitative findings indicate that a specific and directed structure, a lecturer's knowledge base, and confidence and enthusiasm for the material are key components in the development of an effective lecture. These self-reported findings help describe strategies of exemplary emergency medicine lecturers that can be considered by faculty, residents, and other presenters.

Ann Emerg Med. 2011;58:482-489

August 15, 2012

75% of patients with malignant epidural spinal cord compression present with focal weakness, 50% with bowel or bladder dysfunction,16 40%to 90% with sensory abnormalities, 13 and many others with radicular pain or ataxia (due to impingement of the spinocerebellar tract along the posterior aspect of the spinal cord).

EB Medicine.net, 2010

August 14, 2012

An abdominal paracentesis should be performed in anyone suspected of having SBP and without contraindications to the procedure. The finding of an ascitic WBC count of greater than 1000 cells/mL and a polymorphonuclear count of >250 cells/mL is diagnostic. A pH of less than 7.35 in the ascitic fluid is supportive of the diagnosis.

Emerg Med Clin N Am 29 (2011) 293–317

August 12, 2012

Acute Appendicitis Modified Alvarado Scoring System:

Item Score 
Migratory right iliac fossa pain 1
Anorexia 1
Nausea/vomiting 1
Fever > 99.5°F (37.5°C) 1
Tenderness in the right iliac fossa 2
Rebound tenderness in the right iliac fossa 1
Leukocytosis 2
Total 9 points


Ebmedicine.net, March 2012

August 11, 2012

Abdominal radiograph findings in acute appendicitis in children: - Sentinel loop - Air-fluid levels - Right-sided curvature of the spine - Fecolith - Mass in right lower quadrant - Loss of psoas sign - Abdominal pain in children

Emerg Med Clin N Am 29 (2011) 401–428

August 10, 2012

A combined prospective and retrospective observational study of all patients who had Traumatic thoracostomy showed 37% complication rate. Major complications included one intercostal artery laceration, one retroperitoneal placement, and empyema in 2 patients. In multivariate analysis, blunt injury excluding motor vehicle accidents and spontaneous pneumothorax were associated with all complications.

The Journal of Emergency Medicine, Volume 40, Issue 1 , Pages 14-20, January 2011

August 09, 2012

Alfentanil appears effective for ED procedural sedation but displays a rate of airway or respiratory events leading to an intervention similar to that of previous reports of deeper sedation with propofol.

Ann Emerg Med. 2011;57:117-121

August 08, 2012

Infants younger than 3 months of age whose illness is suggestive of the atypical pneumonia syndrome of infancy (ie, tachypnea, mild hypoxemia, absence of fever, and interstitial infiltrates on the chest film) should be treated with a macrolide antibiotic.

Pediatric Emergency Medicine Practice © 2011, ebmedicine. net

August 07, 2012

Rather than displaying the dose-response continuum observed with all other procedural sedation and analgesia agents, ketamine dissociation appears at a dosing threshold of approximately 1.0 to 1.5 mg/kg intravenously (IV) or 3 to 4mg/kg intramuscularly (IM).

Ann Emerg Med. 2011;57:449-461

August 06, 2012

Blood transfusion should be strongly considered in the patient after cardiac arrest whose hemoglobin concentration is less than 6 g/dL. There is almost no indication to transfuse patients after cardiac arrest whose hemoglobin is greater than 10 g/dL.

Emerg Med Clin N Am 30 (2012) 123–140

August 05, 2012

The history and physical examination may yield features suggesting that cardiac arrhythmias to be more or less likely in patients with palpitations. The diagnosis will not typically beconfirmed, however, without cardiac monitoring during symptoms.

Ann Emerg Med. 2011;57: 303-304

August 04, 2012

The addition of a single BNP or NT-proBNP measurement can improve the diagnostic accuracy compared to standard clinical judgment alone in the diagnosis of acute heart failure syndrome among patients presenting to the ED with acute dyspnea:

  • - BNP <100 pg/mL or NT-proBNP <300 pg/mL acute heart failure syndrome unlikely (Approximate LR-=0.1)
  • - BNP >500 pg/mL or NT-proBNP >1,000 pg/mL acute heart failure syndrome likely (Approximate LR+=6).

Emedhome.com, 2011, July

August 03, 2012

For selected appropriate patients with extensive acute proximal deep venous thrombosis, the ACCP guidelines now recommend thrombolysis in addition to anticoagulation to reduce not only the risk of pulmonary embolism but also the risk of subsequent post-thrombotic syndrome and recurrent deep venous thrombosis.

Ann Emerg Med. 2011;57:590-599

August 01, 2012

Managing penetrating neck trauma by physical examination alone is not recommended.

Ebmedicine.net, March 2012, Volume 4, Number 3