American Academy of Emergency Medicine

Fact of the Day - May 2013

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

May 31, 2013

Patients should receive pre-oxygenation in a head-elevated position whenever possible. For patients immobilized for possible spinal injury, reverse Trendelenburg position can be used.

Ann Emerg Med. 2012;59:165-175

May 30, 2013

If there is no evidence of poor digital perfusion after self-injecting with EpiPen, the patient does not require any further treatment and may be discharged.

Annals of EM, Vol. 56:275

May 29, 2013

Standard reservoir facemasks with the flow rate of oxygen set as high as possible are the recommended source of high FiO2 for preoxygenation in the ED.

Ann Emerg Med. 2012;59:165-175

May 28, 2013

The "delta sign" is the classic CT finding of cerebral venous thrombosis - a dense triangle within the superior sagittal sinus that is created by thrombosis within the sinus.

JEM, Vol. 36, pg. 132-137

May 27, 2013

Staphylococcal scalded skin syndrome usually occurs in children, as adults have specific antistaphylococcal antibodies to excrete the staphylococcal toxin through adequate renal clearance.

Mayo Clin Proc, Vol. 84, pg. 838

May 26, 2013

While PCCs are promising enough to have generated expert recommendations for their use in patients with intracranial bleeding receiving VKAs, rigorous studies and those evaluating neurologic outcomes or mortality end points are lacking.

EBmedicine.net, 2012 Vol.2(2)

May 25, 2013

Typical non-rebreather masks used in the ED at flow rates of 15 L/minute deliver only 60% - 70% FiO2, and thus do not maximize the duration of safe apnea. Such non-rebreather masks can deliver FiO2 > 90% by increasing the flow rate to 30 - 60 L/minute. Such flow rates may be achievable on most flow regulators in EDs by continuing to open the valve, though there will be no calibrated markings beyond 15 L/minute.

Ann Emerg Med 2011, Nov 1

May 24, 2013

The risk/benefit of active ventilation during the onset phase of muscle relaxants must be carefully assessed in each patient. In patients at low risk for desaturation (>95% saturation), manual ventilation is not necessary. In patients at higher risk (91% to 95% saturation), a risk-benefit assessment should include an estimation of desaturation risk and the presence of pulmonary pathology. In hypoxemic patients, low-pressure, low-volume, low-rate ventilations will be required.

Ann Emerg Med. 2012;59:165-175

May 23, 2013

Differential Diagnosis For Children With Altered Mental Status : AEIOU Tips:

  • Alcohol abuse
  • Electrolytes, encephalopathy
  • Infection
  • Overdose
  • Uremia
  • Trauma
  • Insulin/hypoglycemia, intussusceptions, inborn errors of metabolism
  • Psychogenic (rare in young children)
  • Seizures, shock, shunt

Pediatric Emergency Medicine Practice, 2011, ebmedicine.net

May 22, 2013

Clinical indicators of potential bladder injury:

  • Suprapubic pain or tenderness
  • Free intraperitoneal fluid on CT or ultrasonographic examination
  • Inability to void or low urine output
  • Clots in urine
  • Signs of perineal or genital trauma
  • Unresponsive, intoxicated, or altered sensorium
  • Preexisting bladder disease or urologic surgery
  • Abdominal distention or ileus

Emerg Med Clin N Am 29 (2011) 501–518

May 21, 2013

Intussusception is not a likely diagnosis in children over 3 years of age and is rare in children older than age 5. In 10% to 20% of children who do have intussusception, diarrhea will be present, and vomiting occurs 60% to 80% of the time.

Pediatric Emergency Medicine Practice, 2012, ebmedicine.net

May 20, 2013

Results from retrospective study demonstrated a negative association between pre-hospital ETI attempts and survival from OOHCA. Individuals having no ETI were 5.46 (95% CI?= 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt. The individuals most likely to have pre-hospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt.

Acad Emerg Med. 2010 Sep;17(9):918-25

May 19, 2013

Changes to the 2010 AHA Guidelines for resuscitation and emergency care of children:

  • The dose of intratracheal administration of epinephrine is suggested to be 10 times the intravenous dose.
  • The dose of intratracheal administration of atropine is increased to 0.04–0.06 mg/kg
  • The routine use of sodium bicarbonate is discouraged during resuscitation
  • The role of vasopressin is not clear, but there is more support for its use during refractory CA
  • Lidocaine use is no longer specifically recommended for the treatment of VF/VT

Emerg Med Clin N Am 30 (2012) 153–168

May 18, 2013

Lorazepam is the drug of choice in alcoholic patients who have had a seizure or who are demonstrating signs of withdrawal. Alcoholic patients who have had a seizure should generally be observed for 4 to 6 hours and, if discharged, referred to a detoxificaton/rehabilitation program, if possible.

Emerg Med Clin N Am 29 (2011) 117–124

May 17, 2013

Treatable causes of diaphragmatic dysfunction include myopathies related to metabolic disturbances such as hypokalemia, hypomagnesemia, hypocalcemia, and hypophosphatemia. Correction of electrolyte and hormonal imbalances and avoidance of neuropathic or neuromuscular blocking agents can restore diaphragmatic strength.

N Engl J Med 2012;366:932-942

May 16, 2013

Headache or migraine is a presenting symptom in 57% to 92% of carotid artery dissections and 69% to 72% of vertebral artery dissections.

EBmedicine.net, April 2012

May 15, 2013

When compared to ultrasound for the diagnosis of acute cholecystitis, HIDA has better sensitivity (88% vs. 50%), specificity (93% vs. 88%), positive predictive value (85%vs 64%), negative predictive value (95% vs. 80%), and accuracy (92% vs. 77%).

American Journal of Emergency Medicine (2011) 29, 91–101

May 14, 2013

Characteristics of the Ketamine "Dissociative State":

  • Dissociation
  • Catalepsy
  • Analgesia
  • Amnesia
  • Maintenance of airway reflexes
  • Cardiovascular stability
  • Nystagmus

Ann Emerg Med. 2011;57:449-461

May 13, 2013

A randomized, single-blind, crossover, prospective study of 70 critically ill adult patients demonstrated that nebulized albuterol and ipratropium do not cause significant tachycardia or tachyarrhythmias. Substitution of levalbuterol for albuterol to avoid tachycardia and tachyarrhythmias is unwarranted.

Chest, Volume 140, Issue 6 (December 2011)

May 12, 2013

In ED record review of 111 discharged patients receiving warfarin, 71% of patients had an international normalized ratio measured, with 49% of values non-therapeutic and 46% with any record of recognition or action. Physicians administered or prescribed potentially interacting drugs for 17% and 13% of patients, respectively.

Ann Emerg Med. 2011;58:192-199

May 11, 2013

In hemodynamically unstable patients (systolic blood pressure <90 mm Hg) with blunt abdominal trauma, bedside ultrasound, when available, should be the initial diagnostic modality performed to identify the need for emergent laparotomy.

Ann Emerg Med. 2011;57: 387-404

May 10, 2013

Topical nonsteroidal anti-inflammatory drugs effectively reduce pain associated with musculoskeletal conditions compared with placebo, with fewer adverse events compared with oral nonsteroidal anti-inflammatory drugs.

Annals of Emergency Medicine, 2012;59 (4)

May 09, 2013

Discordant diagnoses in a retrospective cohort study between emergency physicians and neurologists were observed in 36% of patients. The presence of headache, involuntary movement, and dizziness predicted discordant diagnoses, whereas the presence of tingling and an increased ABCD2 score predicted concordant transient ischemic attack diagnosis.

Ann Emerg Med. 2012;59:19-26

May 08, 2013

Common ED Uses For Ketamine:

In the ED Other Indications
  • Lacerations
  • Reduction of orthopedic fractures and disloca­tions
  • Abscess incision and drainage
  • Burn debridement
  • Lumbar puncture
  • Bone marrow aspiration
  • Dental procedures
  • Central line placement
  • Genitourinary examination under anesthesia
  • Paraphimosis reduction
  • Foreign body removal
  • Tube thoracostomy
  • Prehospital extrication pro­cedures or analgesia
  • Rapid-sequence intuba­tion
  • Treatment of status asth­maticu


EBMedicine.net, January 2011

May 07, 2013

The clinical diagnosis of delirium hinges on the presence of two cardinal features: disruption of attention and disruption of the sleep–wake cycle, which leads to fluctuation in symptoms over the course of a day.

N Engl J Med 2012;366:648-657

May 06, 2013

In acute methanol overdose, ophthalmologic symptoms can range from blurry vision, decreased visual acuity, and photophobia to blindness or the classic “snowstorm” vision.

EBMedicine.net, 2010, Volume 12, Number 11

May 05, 2013

The combination of these 3 examination findings (head impulse test, skew deviation, and spontaneous nystagmus direction) appears to be more sensitive than MRI in acute vertigo.

Mayo Clin Proc 2012;87(3):280-5

May 04, 2013

Pyuria in a urine specimen, in the absence of symptoms, is not an indication for antimicrobial therapy.

EBMedicine.net, January 2012

May 03, 2013

Advantages and Disadvantages of VKAs (Vit K Antagonists):
Proven high effectiveness
Monitoring of INR
Therapeutic window established
Drug interactions
Antidote(s) established
Food interactions
Long action: low thrombosis risk
with poor compliance
Slow onset of action
High bleeding risk


Emedhome.com, February 1, 2012

May 02, 2013

After out-of-hospital cardiac arrest, therapeutic hypothermia was associated with an increased risk of early-onset pneumonia. This complication was associated with prolonged respiratory support and ICU stay, but did not significantly influence ICU mortality.

Am J Respir Crit Care Med 2011 Nov 1; 184:1048

May 01, 2013

Patients are more confident when CT imaging is part of their medical evaluation but have a poor understanding of the concomitant radiation exposure and risk and underestimate their previous imaging experience.

Ann Emerg Med. 2011;58:1-7