American Academy of Emergency Medicine

Fact of the Day - April 2013

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

April 30, 2013

The use of bivalirudin in the prehospital setting leads to a reduced rate of major cardiovascular events compared to a standard treatment with abciximab plus heparin. Bivalirudin is a reasonable choice of treatment in the prehospital setting for patients with STEMI.

American Journal of Emergency Medicine (2012) 30, 12–17

April 29, 2013

Delirium tremens is at the extreme end of the alcohol withdrawal spectrum and is characterized by gross tremor, profound confusion, fever, incontinence, frightening visual hallucinations, and mydriasis. It seldom occurs before the third post-abstinence day.

Emerg Med Clin N Am 29 (2011) 117–124

April 28, 2013

The incidence of cardiogenic shock has decreased in the reperfusion era, especially with the availability of primary PCI for revascularization. However, cardiogenic shock still complicates between 4% and 8% of STEMIs, with an associated mortality rate of 50%.

EMCC/EB Medicine.net, 2011, Volume 1, Number 4

April 27, 2013

For patients who present to the ED with potential acute coronary syndrome, severe pain is not related to likelihood of acute myocardial infarction at presentation or death, acute myocardial infarction or revascularization within 30 days.

Ann Emerg Med. 2011;58:501-507

April 26, 2013

Among inpatients with AMI, the lowest mortality was observed in those with post-admission serum potassium levels between 3.5 and <4.5 mEq/L compared with those who had higher or lower potassium levels.

JAMA. 2012;307(2):157-164

April 25, 2013

It may be technically difficult for one rescuer to achieve an adequate face mask seal and provide ventilation sufficient to achieve chest rise. AHA guidelines corroborate that the presence of 2 rescuers is key to the execution of excellent BVM technique.

Emerg Med Clin N Am 30 (2012) 77–90

April 24, 2013

The most reliable sign of bladder injury is gross hematuria that presents in 93% to 100% of cases. However, if blood is noted at the meatus or if the urinary catheter does not pass easily, urgent assessment of urethral integrity with retrograde urethrography (RUG) should be performed because concomitant bladder and urethral injuries occur in 10% to 29% of patients.

Emerg Med Clin N Am 29 (2011) 501–518

April 23, 2013

In patients suspected of having pyelonephritis, a urine culture and susceptibility test should always be performed, and initial empiric therapy should be tailored appropriately on the basis of the likely infecting uropathogen. (B-III Evidence).

EBMedicine.net, January 2012

April 22, 2013

The differential diagnosis of subacute confusional state in a patient with liver disease includes five major syndromes: hepatic encephalopathy, Wernicke's encephalopathy, alcohol withdrawal, occult seizures, and infection.

N Engl J Med 2012;366:745-755

April 21, 2013

According to CDC guidelines, HIV postexposure prophylaxis may be initiated within 72 hours window for eligibility for HIV postexposure prophylaxis.

NEJM, Vol. 361, pg. 1773

April 20, 2013

Appendiceal perforation in children is more common than in adults and correlates directly with duration of symptoms before surgery. Unlike in adults, the risk of perforation within 24 hours of onset is substantial and it increases in a linear fashion with duration of symptoms.

American Journal of Emergency Medicine (2011) 29, 890–893

April 19, 2013

Differential Diagnosis For Children With Hypotension :

Vomiting and diarrhea
Glycosuric diuresis
Blood loss

Neurogenic Shock
Central nervous system and spinal injuries

Distributive Shock
Toxic ingestions

Cardiogenic Shock
Aortic coarctation and various other ductal-dependent lesions
Aortic stenosis
Conduction abnormalities

Pediatric Emergency Medicine Practice, 2011, emedicine.net

April 18, 2013

There is a lack of evidence to support the use of therapeutic hypothermia for closed head injury; specifically, there is no benefit in mortality or neurologic outcome compared with normothermic controls.

Ann Emerg Med. 2011;57: 387-404

April 17, 2013

Apneic oxygenation can extend the duration of safe apnea when used after the administration of sedatives and muscle relaxants. A nasal cannula set at 15 L/minute is the most readily available and effective means of providing apneic oxygenation during ED tracheal intubations.

Ann Emerg Med. 2012;59:165-175

April 16, 2013

Avulsion fractures of the base of the fifth metatarsal heal beautifully without complications. Jones fractures frequently have non-unions, recurrent fractures and chronic problems.

Emedhome.com, March 2011

April 15, 2013

Patients should be positioned to maximize upper airway patency before and during the apneic period, using ear-to–sternal notch positioning. Nasal airways may be needed to create a patent upper airway. Cricoid pressure may negatively affect apneic oxygenation, but studies examining this question in the setting of modern emergency airway management do not exist to our knowledge.

Ann Emerg Med. 2012;59:165-175

April 14, 2013

A retrospective analysis of 129 cases evaluating feasibility of nebulized naloxone use by prehospital providers for patients with suspected opioid showed that 23 (22%) had complete response, 62 (59%) had partial response, and 20 (19%) had no response. Eleven cases (10%) received rescue naloxone, no case required assisted ventilation, and no adverse events occurred.

Prehosp Emerg Care. 2011 Dec 22

April 13, 2013

In the second and third decades of life, less than 1% of patients with shoulder dislocations also had fractures. Because these patients have a sufficiently low risk of fracture, routine pre-reduction x-rays may not be necessary for them.

American Journal of Emergency Medicine (2011) 29, 609–612

April 12, 2013

A prospective cohort analysis of 691 ED patients who received intravenous morphine or hydromorphone demonstrated initial dosages variation by a factor of 27 (from 1 mg of Morphine to 4 mg of hydromorphone). In addition, only 21% of patients had their opioid titrated.

Am J Emerg Med. 2010 Nov;28(9):1041-1050

April 11, 2013

Studies from 4 countries suggest that primary closure of incised and drained abscesses results in faster healing and similar low abscess recurrence rates than after secondary closure. Thesestudies provide a foundation for which clinical trials can be conducted in the United States.

American Journal of Emergency Medicine (2011) 29, 361–366

April 10, 2013

The best choice for antibiotics for community-acquired mixed, necrotizing infections is a combination of ampicillin-sulbactam plus clindamycin plus ciprofloxacin.

EBMedicine.net, January 2012

April 09, 2013

The treatment of choice for listeriosis is full-dose intravenous ampicillin. In patients with severe infection or in an immunocompromised host, gentamicin is often added for synergy. Central nervous system disease requires at least 21 days of therapy; more therapy is required if an abscess or cerebritis is present or if a patient is highly immunosuppressed.

N Engl J Med 2012;366:1039-1045

April 08, 2013

Review of randomized clinical trials comparing norepinephrine versus dopamine in critically ill patients with septic shock demonstrated statistically significant superiority of norepinephrine over dopamine for the outcome of in-hospital or 28-day mortality and statistically significant decrease in the rate of cardiac arrhythmias in the norepinephine group as compared to the dopamine group.

Intensive Care Med 2011 Mar 24

April 07, 2013

CRASH-2 data showed that thrombolytic administration within 1 hour of injury significantly reduced mortality due to hemorrhage compared to placebo (5.3% vs. 7.7%; relative risk, 0.68) as did TA administration within 1 to 3 hours (4.8% vs. 6.1%; RR, 0.79). However, TA administration within 3 to 8 hours after injury significantly increased mortality due to hemorrhage (4.4% vs. 3.1%; RR, 1.44). The effect of TA did not vary by systolic blood pressure, Glasgow Coma Scale score, or type of trauma (blunt, penetrating, or both).

Lancet 2011 Mar 26; 377:1096

April 06, 2013

Twenty-five percent of eclamptic seizures occur in the postpartum period. Magnesium is the treatment of choice for eclamptic seizures. Labetalol and hydralazine are the antihypertensive agents of choice in eclampsia. The definitive treatment of eclampsia is delivery of the fetus.

Emerg Med Clin N Am 29 (2011) 109–116

April 05, 2013

Therapeutic hypothermia -Rewarming phase: - Re-warm at a rate of 0.25 to 0.5C/h - Monitor electrolytes and replace to high normal values - Rapid re-warming may reinitiate catabolic processes and worsening outcome

Emerg Med Clin N Am 30 (2012) 123–140

April 04, 2013

Therapeutic hypothermia -Maintenance phase: - Maintain hypothermia at 32 to 34C - Continue for 12 to 24 hours - Monitor electrolytes and replace to high normal values: Magnesium, Phosphate, Potassium, Calcium - Monitor glucose and treat hyperglycemia - Monitor coagulation parameters; Prothrombin time; Activated partial thromboplastin time; Platelets

Emerg Med Clin N Am 30 (2012) 123–140

April 03, 2013

Therapeutic hypothermia -Induction phase:

  • Cool as early as possible, even if Pt going for percutaneous coronary intervention (PCI)
  • Target temperature 32 to 34C
  • Administer cold intravenous fluids (30 mL/kg bolus of isotonic crystalloid)
  • Use surface cooling methods
  • Place temperature-sensing Foley catheter, esophageal temperature probe, rectal probe, or intravascular device
  • Control shivering

Emerg Med Clin N Am 30 (2012) 123–140

April 02, 2013

Both B-blockers and calcium channel blockers have been shown to inhibit the contraction of the smooth muscle responsible for ureteral spasms (while still allowing antegrade stone propagation). Both tamsulosin and nifedipine have been shown to expedite the expulsion of moderate-sized distal ureteral calculi.

Mayo Clinic Proc. January 2011 86(10: 70-74

April 01, 2013

A study demonstrated that non-white patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.

American Journal of Emergency Medicine (2011) 29, 752–756