American Academy of Emergency Medicine

Fact of the Day - February 2014

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

February 28, 2014

Fluoroquinolones now carry an FDA warning describing peripheral neuropathy as a serious side effect. Patient’s should be warned of this side effect and instructed to notify a physician if they develop neuropathy.


February 27, 2014

In the United States over 500,000 people experience cardiac arrest each year and less than 15% survive. Less than 40% of out-of-hospital cardiac arrests receive bystander CPR. Survival to discharge rates fall by 30% if compression depths are less than 38 mm (rather than >50 mm, as recommended). Be sure to monitor for high-quality CPR!

Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital. Circulation. 2013: 128: 417-435.

February 26, 2014

A recent validation study of 1,582 patients showed a sensitivity for need for neurosurgical intervention of 100% (Canadian CT Rule) and 82% (New Orleans Criteria). The sensitivity for clinically significant CT findings was 95% for the Canadian CT Rule and 86% for the New Orleans Criteria. According to this study, the Canadian CT Head Rule had a higher sensitivity.

Bouida W, Marghli S, Souissi S, et al. Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study. Ann of Emerg Med. 2013;61(5): 521-527.

February 25, 2014

Patients with significantly elevated ethanol levels can spend many hours “sleeping it off” in the ED. While there is a variation in the rate of ethanol metabolism, ethanol clearance from the blood generally occurs at approximately 15 to 20 mg/dL. Chronic alcohol abusers can often clear ethanol more rapidly, at rates of at least 25 to 35 mg/dL.

Cowan E, Su M. Ethanol Intoxication in Adults. In: UpToDate, Basow DS (ed), Waltham, MA: UpToDate. 2013.

February 24, 2014

There is substantial overlap between the clinical pictures of sympathomimetic and anticholinergic toxicity. One way to differentiate the two is diaphoresis in sympathomimetics (think cocaine) and dry skin in anticholinergics.

Kazzi ZN, Shih R, eds. AAEM Resident & Student Association Toxicology Handbook. 2nd ed. AAEM/RSA; 2011.

February 23, 2014

Many studies have linked chronic renal disease and cardiovascular risk. Impaired kidney function and increased urine albumin independently increase the risk of cardiovascular disease by two to four times. Remember that when evaluating for cardiovascular disease risk factors.

Gansevoort RT, Correa-Rotter R, Hemmelgarn BR, et al. Chronic Kidney Disease and Cardiovascular Risk: Epidemiology, Mechanisms, and Prevention. Lancet. 2013; 382(9889): 339-352.

February 22, 2014

Recent STEMI guidelines have removed “new or presumably new” LBBB as a “STEMI-equivalent.” In cases of LBBB and suspected MI, consider the Sgarbossa Criteria: ST-elevation ≥ 1 mm concordant with the QRS in any lead (5 points); ST-depression ≥ 1 mm in V1, V2, or V3 (3 points); and ST-elevation ≥ 5 mm discordant with the QRS in any lead (2 points). A score ≥ 3 is considered >95% specific for acute MI.

Qiangjun C, Mehta N, Sgarbossa EB, et al. The left bundle-branch puzzle in the 2013 ST-elevation myocardial infarction guideline: From falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time? Am Heart J. 2013; 166:409-413.

February 21, 2014

Ventilation-Perfusion (VQ) scanning is equivalent to approximately 22 chest x-rays (2.2 mSv) while CT chest PE-protocol is equivalent to approximately 150 chest x-rays (15 mSv). It should be noted; however, in a pregnant female radiation exposure to the fetus is slightly lower with CT than VQ scanning.

Lee CI, Elmore JG. Radiation-related risks of imaging studies. In: UpToDate, Basow DS (ed), Waltham, MA: UpToDate. 2013.

February 20, 2014

When using lidocaine for local anesthesia, plain lidocaine may generally be used in doses of up to 4.5 mg/kg (max 300 mg) and lidocaine with epinephrine in doses up to 7 mg/kg (max 500 mg). For example, using 1% plain lidocaine (10 mg/mL) in a 25 kg child, the maximum safe dosage would be 11.25 mL. 

McGee DL. Local and Topical Anesthesia. In: Roberts & Hedges Clinical Procedures in Emergency Medicine. 5th Ed. Philadelphia, PA: Saunders; 2010: 496.

February 19, 2014

In superficial traumatic wounds requiring suturing, using clean non-sterile gloves, rather than sterile gloves, does not increase rates of infection. Note that complicated wounds (bites, tendon injury, open fracture, open >12hrs, etc) and potentially immunocompromised patients (diabetes) were excluded from this study.

Perelman VS, Francis GJ, Rutledge T, et al. Sterile versus Nonsterile Gloves for Repair of Uncomplicated Lacerations in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2004; 43:362-370.

February 18, 2014

Patients occasionally report an allergy to “all” local anesthetics, with little additional information on specific class (esters or amides) or whether the reaction was actually due to the methylparaban preservative. An alternative strategy can include local infiltration of a dilute 1% diphenhydramine (Benadryl) solution. Dilute 1mL of the standard 5% parenteral diphenhydramine in 4mL of saline and use in place of lidocaine. Note that the duration of action is shorter than that of lidocaine.

McGee DL. Local and Topical Anesthesia. In: Roberts & Hedges Clinical Procedures in Emergency Medicine. 5th Ed. Philadelphia, PA: Saunders; 2010: 498.

February 17, 2014

Patients had important information deficits when leaving the ED, and information transmission needs to be improved. The physician–patient discharge conversation seems an ideal opportunity for enhancing patient informedness. Standardization of discharge procedures and training physicians in how to ensure that patients actually understand the information provided are needed.

Hans Marty, Yvonne Bogenstätter, Gabriela Franc, Franziska Tschan, Heinz Zimmermann. Emerg Med J 2013;30:53-57

February 16, 2014

Emergency cricothyroidotomy performed by inexperienced clinicians—surgical technique versus indicator-guided puncture technique. In this human cadaver study the indicator-guided puncture technique produced more major complications and more failures than the standard surgical technique. In the hand of the inexperienced operator the standard surgical approach seems to be a safe procedure, which can successfully be performed within an adequate time. This technique cannot be recommended for inexperienced operators.

Matthias Helm, Björn Hossfeld, Christian Jost, Lorenz Lampl, Tobias Böckers. Emerg Med J 2013;30:646-649

February 15, 2014

Vomiting should be a prompt predictor of stroke outcome. Compared with patients without vomiting, the risk of death was significantly higher in patients with vomiting at the onset of stroke. Vomiting should be an early predictor of the outcome.

Kazuo Shigematsu, Osamu Shimamura, Hiromi Nakano, Yoshiyuki Watanabe, Tatsuyuki Sekimoto, Kouichiro Shimizu, Akihiko Nishizawa, Masahiro Makino. Emerg Med J 2013;30:728-731

February 14, 2014

Topical lignocaine to improve oral intake in children with painful infectious mouth ulcers. Viscous lignocaine is no better than a flavored gel placebo in improving oral intake in children with painful infectious mouth ulcers.

S. Hopper, C. Tancharoen, M. McCarthy, K. J. Lee, A. Davidson, F. Babl. Emerg Med J 2013;30:868

February 13, 2014

Although the physicians had a high degree of accuracy in identifying patients with alcohol intoxication based on their olfactory sense, they still falsely overestimated intoxication in significant numbers of non-intoxicated trauma patients.

Shweta Malhotra, Kannan Kasturi, Nachama Abdelhak, Lorenzo Paladino, Richard Sinert. Emerg Med J 2013;30:923-925

February 12, 2014

Effect of paralytic type on time to post-intubation sedative use in the emergency department: Patients intubated with rocuronium had greater delays in post-intubation sedative initiation compared with succinylcholine.

John Watt, Albert Amini, Brittany Traylor, Richard Amini, John Sakles, Asad Patanwala. Emerg Med J 2013;30:893-895

February 11, 2014

Rapid 13C Urea Breath Test to Identify Helicobacter pylori Infection in Emergency Department Patients with Upper Abdominal Pain. In this study, H. pylori infection was present in 1 in 4 patients with epigastric pain, and testing with a 13C  Urea Breath Test was feasible.

Andrew C. Meltzer, Rebecca Pierce, Derek A.T. Cummings, Jesse M. Pines, Larissa May, Meaghan A. Smith, Joseph Marcotte, Melissa L. McCarthy, West J Emerg Med. 2013 May; 14(3): 278–282. doi: 10.5811/westjem.2012.12.15173

February 10, 2014

In a large heterogenous group of clinicians who typically care for trauma patients, the sonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracic ultrasound may be helpful in the initial evaluation of patients with truncal trauma.

Bon S. Ku, J. Matthew Fields, Brendan Carr, Worth W. Everett, Vincent H. Gracias, Anthony J. Dean, West J Emerg Med. 2013 March; 14(2): 103–108. doi: 10.5811/westjem.2012.12.12663

February 09, 2014

Fingertip POC lactate measurement is an accurate method to determine lactate levels in infected ED patients with normal or modestly elevated lactate values and significantly decreases time to test results.

David F. Gaieski, Byron C. Drumheller, Munish Goyal, Barry D. Fuchs, Frances S. Shofer, Kara Zogby, West J Emerg Med. 2013 February; 14(1): 58–62. doi: 10.5811/westjem.2011.5.6706

February 08, 2014

Patients with severe pain were randomized to a 2 mg bolus of hydromorphone or a “1 +1” mg protocol for pain management.  Sixty minutes later patients were asked if they would like more pain medication.  Regarding pain relief, there was no significant difference between the two groups and the “1+1” protocol actual had an opioid sparing effect.

Chang AK, Bijur PE, Lupow JB, Gallagher EJ. Randomized clinical trial of the 2 mg hydromorphone bolus protocol versus the "1+1" hydromorphone titration protocol in treatment of acute, severe pain in the first hour of emergency department presentation. Ann Emerg Med. 2013;62(4):304-10.

February 07, 2014

Retropharyngeal abscess in the pediatric population can be confused with subglottic infections.  One way to differentiate retropharyngeal vs subglottic infection is to assess the patient’s neck range of motion.  An unwillingness to look side to side and reluctance to extend the neck is more common in retropharyngeal abscesses.

Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders, 2013. Print.

February 06, 2014

Coral Snakes are poisonous, King snakes are not. Differentiate them by  their colors.

Red and Yellow = Coral Snake 
Red and Black = King Snake

RED next to yellow, Kill a fellow
RED next to black, Venom lack

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010

February 05, 2014

High Altitude Pulmonary edema is a form of noncardiogenic pulmonary edema, it occurs 2-4 days after arrival to high altitude. It is the most common cause of death related to high altitude. 

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010

February 04, 2014

Hawaii is the only state in the US that is Rabies free. 

Caused by neurotropic rhabdovirus of genus Lyssavirua.

The virus creates NEGRI BODIES in nuclei of neurons, manufactures copies of itself that then bud out to infect other neurons which then travels ante grade to salivary glands where it can be excreted

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010

February 03, 2014

Hydrofluoric Acid is an acid solution that causes Coagulative Necrosis but the free fluoride ion is actually responsible for most of the damage.  Flouride scavages cations such as Ca+ and Magnesium resulting in Hypocalcemia and hypomagnesia. 

Treatment is copious irrigation, removal of blisters, and calcium gluconate gel, IM, or IA therapy for deep wounds

M: inject .5 ml/cm of 10% calcium gluconate SubQ.
IA: 10ml soln of 10% calcium gluconate in 40-50ml of NS infused over 4 hours)

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010

February 02, 2014

Besides GABA, GLUTAMATE is the other neurotransmitter that is involved in the sedative-hypnotic withdrawal syndrome (benzo withdrawal)

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010

February 01, 2014

Zanamivir is an inhaled neuraminidase inhibitor used to treat influenza or as chemoprophylaxis in exposed patients deemed to be high risk. It is associated with wheezing and has been connected to severe bronchospasm with subsequent death in patients who have underlying lung disease. For this

Tintinnalli, 7th edition, Chapter 157, “Occupational Exposure, Infection Control, and Standard Precautions”