American Academy of Emergency Medicine

Fact of the Day - January 2013

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

January 31, 2013

The added value of plain radiographs is too limited to advocate their routine use in the diagnostic workup of patients with acute abdominal pain, because few diagnoses change and the level of confidence were mostly not affected.

American Journal of Emergency Medicine (2011) 29, 582–589.e2

January 30, 2013

Bacterial pneumonia due to S pneumoniae, Streptococcus pyogenes (group A beta-hemolytic streptococcus [GABHS]), or Staphylococcus aureus must be considered in severely ill infants and toddlers who have one of the following signs or symptoms: a rapid onset and progression of symptoms, radiographic evidence of lobar or diffuse infiltrates, a large pleural effusion, or a lung abscess.

Pediatric Emergency Medicine Practice, 2011, ebmedicine.net

January 29, 2013

Factors associated with a successful cardioversion of patients who were admitted to the emergency department with acute AF and a duration of shorter than 48 hours included lower blood pressure on admission (P = .002), a shorter time interval between the onset of AF and admission to the ED (P = .003), and adherence to treatment guidelines (P b .0001).

American Journal of Emergency Medicine (2011) 29, 534–540

January 28, 2013

CT and MRI have shown that cricoid pressure causes lateral displacement of the esophagus in more than 90% of patients and laryngeal/tracheal compression in 80%. Numerous studies have found that cricoid pressure hinders bag-valve-mask ventilation, increases peak inspiratory pressure, reduces tidal volumes, and may limit the effectiveness of apneic oxygenation.

Ann Emerg Med 2011 Nov 1

January 27, 2013

Visitors to different EDs experience a large variation in their probability of leaving without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen.

Ann Emerg Med. 2011;58:24-32

January 26, 2013

Clinician-performed US is a repeatable examination that can provide vital diagnostic information at the bedside without exposing a patient to ionizing radiation. In the unstable patient, a goal-directed ultrasound examination may be the most efficient way to narrow a diagnosis.

Emerg Med Clin N Am 29 (2011) 175–193

January 25, 2013

Risk factors for uncomplicated sporadic and recurrent cases of cystitis and pyelonephritis include sexual intercourse, use of spermicides, previous urinary tract infection, a new sex partner (within the past year), and a history of urinary tract infection in a first-degree female relative.

N Engl J Med 2012;366:1028-1037

January 24, 2013

AIMS 65 is a simple, accurate risk score that predicts in-hospital mortality, LOS, and cost in patients with acute upper GI bleeding. The 5 factors present at admission with the best discrimination were albumin less than 3.0 g/dL, international normalized ratio greater than 1.5, altered mental status, systolic blood pressure 90 mm Hg or lower, and age older than 65 years.

Gastrointest Endosc 2011 Dec 74:1215

January 23, 2013

Over the past 35 years, ED management of atraumatic abdominal pain has become time, money, and resource intense. Widespread use of sophisticated imaging has had a small impact on diagnostic specificity but has not produced lower admission rates or fewer cases of missed surgical illness.

American Journal of Emergency Medicine (2011) 29, 711–716

January 22, 2013

ACEP recommends that emergency physicians who have received the appropriate training and skills necessary to safely provide procedural sedation should be eligible for credentialing in all levels of procedural sedation.

Ann Emerg Med. 2011;57:469

January 21, 2013

The reported prevalence of pneumonia in children with abdominal pain ranges from 2.7% to 5%. Therefore, in the evaluation of pediatric abdominal pain, it is important to consider evaluating for pneumonia as an occult cause.

Emerg Med Clin N Am 29 (2011) 401–428

January 20, 2013

In treating Acute Uncomplicated Cystitis Nitrofurantoin monohydrate/macrocrystals is an appropriate choice for therapy due to minimal resistance, decreased side effects, and increased efficacy comparable to 3 days of trimethoprim-sulfamethoxazole. (A-I evidence).

EBMedicine.net , January 2012

January 19, 2013

Images Required For Complete Skeletal Survey:

  • Skull (AP and lateral; consider opposite lateral and Towne projections)
  • Cervical spine (AP and lateral)
  • Chest (to include ribs and thoracic spine: AP, lateral, and oblique)
  • Pelvis (AP; include lower lumbar spine)
  • Lumbar spine (lateral)
  • Abdomen, pelvis, lumbosacral spine (AP)
  • Humerus, radius, ulna (AP)
  • Hands (oblique)
  • Femur, tibia, fibula (AP), feet (AP)

Pediatric Emergency Medicine Practice , May 2011 , ebmedicine.net

January 18, 2013

Neutropenic fever is defined as a single temperature measurement >=38.3°C (101°F) or a sustained temperature >=38°C (>=100.4°F) for more than 1 hour in a patient with an absolute neutrophil count (ANC) of either < 500 cells/µL or < 1000 cells/µL with a predicted nadir of < 500 cells/µL over the subsequent 48 hours.

EBMedicine.net, March 2010

January 17, 2013

Recommendations from a number of professional societies advocate vancomycin as the first-line agent for patients with severe C. Difficile infection, since a small increment in efficacy may be critical in patients with fulminant disease.

N Engl J Med 2008;359:1932-40

January 16, 2013

Patients with substance abuse problems report more severe pain and functional interference, more psychiatric illness and mood distress, and more chronically painful conditions. Effective treatment of this challenging patient population requires treating the entirety of their medical, psychiatric, and addictive diseases.

American Journal of Emergency Medicine (2011) 29, 50–56

January 15, 2013

Hydroxocobalamin is a naturally occurring analog of vitamin B12 acts as a cyanide “chelator,” replacing the central cobalt-bound hydroxyl group with cyanide. The risk/benefit ratio appears low for hydroxocobalamin, and it should make an excellent first-line therapy in the treatment of cyanide poisoning.

American Journal of Emergency Medicine (2012) 30, 231–235

January 14, 2013

15% of the time a lateral talar process fracture is missed during the initial visit . It pretends to be a simple ankle sprain and is subtle enough to evade detection on plain x-rays.

Emedhome.com, March 2011

January 13, 2013

Although important exceptions exist, weakness that is predominantly proximal is usually indicative of a myopathic disorder, and weakness that is predominantly distal indicates a neuropathic condition. Segmental weakness involving selected myotomes in a multifocal distribution may implicate a motor neuropathy (disorder of the anterior horn cell).

N Engl J Med 2012;366:944-954

January 12, 2013

Initiation Of Temporary Pacing In Acute Myocardial Infarction:

  • Refractory sinus node dysfunction
  • Mobitz-2 second-degree AV block with anterior myocardial infarction
  • Third-degree AV block with anterior myocardial infarction
  • Alternating bundle branch block
  • Alternating Wenckebach block
  • New bundle branch block with anterior myocardial infarction
  • Bifasicular block with first degree AV block
  • AV block associated with marked bradycardia and symptoms

EMCC/EBMedicine.net, 2011, Volume 1, Number 4

January 11, 2013

Patients with toxoplasma infection typically present subacutely with headache, fever, changes in mental status, and focal neurologic deficits. Imaging studies of the brain reveal characteristic rim-enhancing lesions that are usually multifocal but may be solitary in up to 30% of cases.

N Engl J Med 2012;366:745-755

January 10, 2013

Current literature does not support intravenous use of meperidine as a first-line opioid analgesic mostly due to the severe neurotoxic effects. Should meperidine be used, a loading dose of 1-1.5 mg/kg with additional titration of 1 mg/kg is the recommended approach but might need to be reduced in elderly patients due to its renal and neurotoxic effects.

Emedhome.com, March 2012

January 09, 2013

Complications most commonly associated with emergent pericardiocentesis include cardiac dysrhythmias, cardiac puncture, pneumothorax, and coronary-vessel injury. Other complications include: peritoneal puncture (with the subxiphoid approach), liver or stomach injury (also with the subxiphoid approach), puncture of the internal thoracic artery (with the parasternal approach), and diaphragmatic injury (with the subxiphoid approach).

N Engl J Med 2012;366:e17

January 08, 2013

The common clinical features of HIV-associated psychosis include sudden onset without a prodrome, delusions (87% of patients), hallucinations (61%), and mood symptoms (81%). In HIV-associated psychosis, neurologic findings are typically limited and CT findings are nonspecific; however, EEGs are abnormal in 50% of cases.

N Engl J Med 2012;366:648-657

January 07, 2013

There is no convincing evidence that patients with acute spontaneous intracerebral hemorrhage benefit from hemostatic agents or experience more thromboembolic serious adverse events.

Ann Emerg Med. 2011;57: 66-67

January 06, 2013

Patients with an adequate respiratory drive should receive pre-oxygenation for 3 minutes or take 8 breaths, with maximal inhalation and exhalation.

Ann Emerg Med. 2012;59:165-175

January 05, 2013

When compared with ketamine alone for pediatric orthopedic reductions, the combination of ketamine and propofol produced slightly faster recoveries while also demonstrating less vomiting, higher satisfaction scores, and similar efficacy and airway complications.

Ann Emerg Med. 2011;57:425-433

January 04, 2013

Indications For Hemodialysis In Methanol And Ethylene Glycol Toxicity:

  • Metabolic acidosis (pH < 7.25-7.30)
  • Vision abnormalities
  • Renal failure
  • Electrolyte abnormalities not responsive to conventional treatment
  • Hemodynamic instability refractory to intensive care treatment
  • Serum concentration > 50 mg/dL

EBMedicine.net, 2010, Volume 12, Number 11

January 03, 2013

Therapeutic hypothermia with conventional cooling methods improves survival and neurologic outcomes at hospital discharge for patients who have experienced a cardiac arrest.

Ann Emerg Med. 2011;58: 282-283

January 02, 2013

Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the following minor criteria for severe CAP (B-II): Respiratory rate > 30 breaths/min ; Arterial oxygen pressure/fracture of inspired oxygen (PaO2/FiO2) ratio < 250; Multilobar infiltrates; Confusion; Blood urea nitrogen > 20 mg/dL ; Leukopenia ; Thrombocytopenia; Hypothermia; Hypotension requiring aggressive fluid resuscitation.

EBMedicine.net, January 2012

January 01, 2013

Multiple studies demonstrated that pelvic ultrasound is to be diagnostic of IUP or ectopic in approximately 70% to 75% of symptomatic first-trimester pregnant patients.

EBMedicine.net, 2011