American Academy of Emergency Medicine

Fact of the Day - April 2014

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

April 30, 2014

In a study of 195 pediatric patients, concomitant injuries to other levels in the spine occurred in 32% of patients with an initial identified spinal injury.

Mahan ST, Mooney DP, Karlin LI, et al. Multiple level injuries in pediatric spinal trauma. J Trauma. 2009 Sep;67(3):537-42.

April 29, 2014

When standard treatment (epinephrine, antihistamines, steroids) is unsuccessful in the treatment of ACE Inhibitor-induced angioedema, consider adding FFP.

Hassen GW, Kalantari H, Parraga M, et al. Fresh frozen plasma for progressive and refractory angiotensin-converting enzyme inhibitor-induced angioedema. J Emerg Med. 2013 Apr;44(4):764-72.

April 28, 2014

When prescribing medications out of the ED, remember to warn patients about their side effects. As an example, tetracyclines (especially doxycycline), thiazide diuretics, quinolones, voriconazole, and amiodarone are well known to have phototoxic side effects.

Stern RS. Clinical practice. Exanthematous drug eruptions. N Engl J Med. 2012 Jun 28;366(26):2492-501.

April 27, 2014

While previous approaches to Crotaline snake bites have included cryotherapy (cold water immersion), incision and suction, and electric shock therapy, most of these have proven to be of little benefit or harmful. Current recommendations are only to immobilize the extremity and consider antivenin.

McKinney PE. Out-of-hospital and interhospital management of crotaline snakebite. Ann Emerg Med. 2001 Feb;37(2):168-74.

April 26, 2014

Vancomycin administration is warranted in the context of suspected MRSA infection or when severe systemic illness with a high risk of mortality is present, but incorrect dosing in the ED can result in inefficacy or development of resistance to the drug. The correct dosage is 15-20 mg/kg of body weight.

Fuller, B. M., et al. (2013). "Emergency Department Vancomycin Use: Dosing Practices and Associated Outcomes." The Journal of Emergency Medicine 44(5): 910-918.

April 25, 2014

For up to 2 weeks post-partruition, the immune, respiratory, and cardiovascular changes that occur during pregnancy do not immediately return to baseline and the patient continues to be at an increased risk for complications (including death) from H1NI and seasonal influenza.

Shiber, J. "Post-partum is Also a Risk Factor for Severe H1N1 Disease." The Journal of Emergency Medicine(0).

April 24, 2014

Compartment syndrome as a result crotalinae envenomation is rare and traditionally treated via fasciotomy. However, antivenin administration and supportive care reduced lower-extremity compartment pressures in a 17-month-old following a copperhead (Agkistrodon contortrix) bite.

Mazer-Amirshahi, M., et al. "Elevated Compartment Pressures from Copperhead Envenomation Successfully Treated with Antivenin." The Journal of Emergency Medicine(0).

April 23, 2014

Bezoars are classified based on their contents, with pharmacobezoars resulting from accumulation of long-acting medications and trichobezoars consisting of ingested hair. First-line treatment involves attempts to dissolve the obstruction (e.g. with Coca-Cola) followed by endoscopy or surgery if dissolution is unsuccessful.

Yeh, J., et al. "Bezoar." The Journal of Emergency Medicine(0).

April 22, 2014

Skin dimpling or “puckering” is a rare complication of displaced supracondylar humeral fracture in which the proximal humeral fragment transverses the brachialis muscle and penetrates the overlying dermis. Puckering can be alleviated via axial traction; however, if left untreated, necrosis of the area could result followed by conversion to an open fracture.

Aneja, A., et al. "Skin Dimpling after a Closed Proximal Humerus Fracture." The Journal of Emergency Medicine(0).

April 21, 2014

Characterized by systemic oxidation of deoxyhemoglobin and typically caused by exposure to toxins, methemoglobinemia can also be of congenital origin accompanying a genetic cytochrome b5 reductase deficiency.

Levine, M., et al. "Methemoglobinemia after a Mediastinal Stab Wound." The Journal of Emergency Medicine(0).

April 20, 2014

Due to similar clinical presentations and EKG changes, Takutsubo cardiomyopathy or "broken heart syndrome" can be easily mistaken for acute coronary syndrome and commonly afflicts postmenopausal women and those in acute mental or physical stress.

Ritchie, D., et al. "Takutsubo Cardiomyopathy and Flash Pulmonary Edema In a Trauma Patient." The Journal of Emergency Medicine(0).

April 19, 2014

The SSRI citalopram taken concurrently with levosulpiride (which possesses class III antiarrhythmic properties) can cause severe QT interval prolongation associated with palpitations and syncopal events.

Agosti, S., et al. "Citalopram and levosulpiride: a dangerous drug combination for QT prolongation." The American Journal of Emergency Medicine(0).

April 18, 2014

Administration of sub-cutaneous epinephrine less than 25 minutes after the onset of insect-sting anaphylaxis reverses the hypotension and bronchospam associated with this condition while also decreasing mortality.

Fortenberry, J. E., et al. (1995). "Use of Epinephrine for Anaphylaxis by Emergency Medical Technicians in a Wilderness Setting." Annals of Emergency Medicine 25(6): 785-787.

April 17, 2014

Penicillin "allergy" history is often inaccurate but is linked to longer hospital stay, significantly more antibiotic use, and increased prevalence of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) infections.

Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: A cohort study. J Allergy Clin Immunol. 2014; 133:790-798.

April 16, 2014

In the Target Temperature Management 33o C versus 36o C after Cardiac Arrest (TTM) study, conducted in 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac origin, hypothermia to target temperatures of either 33°C or 36°C, maintained for up to 36 hours, yielded comparable survival and neurologic outcomes at 6 months.

Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med. Nov 17 2013;[Medline].

April 15, 2014

Reports estimate that only 10%–20% of patients with a self-reported PCN allergy are ultimately found to be truly allergic when assessed by skin testing.

Khasawneh FA, Slaton MA, Katzen SL, Woolbert AA, Anderson SD, Parker MB, Anderson RM, Haase KK, Smalligan RD. The prevalence and reliability of self-reported penicillin allergy in a community hospital. Int J Gen Med. 2013 Dec 6;6:905-9

April 14, 2014

Heavy drinking has been directly linked to the development of atrial fibrillation.

Samokhvalov AV et al. Alcohol consumption as a risk factor for atrial fibrillation: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil. 2010 Dec; 17(6):706-12.

April 13, 2014

Hawaii is the only state that is rabies free. The mongoose is the most common carrier of rabies in Puerto Rico.

Blanton JD, et al. Rabies surveillance in the United States during 2011. J Am Vet Med Assoc. 2012; 241(6): 712-22.

April 12, 2014

Replacement of the stylet before removing the spinal needle during a lumbar puncture has been shown to decrease the incidence of postdural puncture headaches.

Waise S, Gannon D. Reducing the incidence of post-dural puncture headache. Clin Med. 2013 Feb; 13(1): 32-4.

April 11, 2014

CDC estimates that each year roughly 1 in 6 Americans (or 48 million people) get sick, 128,000 are hospitalized, and 3,000 die of foodborne diseases.


April 10, 2014

Cocoa has been shown to increase cognition in elderly patients

Sorond FA et al. Neurovascular coupling, cerebral white matter integrity, and response to cocoa in older people. Neurology. 2013 Aug 7. [Epub ahead of print]

April 09, 2014

Latex allergy is increased in populations with chronic occupational exposure to latex. It is found in 8-12% of health care workers and in at least 10% of rubber industry workers. Symptoms of latex allergy have been described in 14% of a group of EMS providers and in 54% of a pediatric ED staff.

Ahmed DD, Sobczak SC, Yunginger JW. Occupational allergies caused by latex. Immunol Allergy Clin North Am. May 2003; 23(2): 205-19.

April 08, 2014

Sheer stresses at the ankle joint can be detrimental to cartilage and lead to arthritis. 1 mm of talar shift results in a 40% decrease in tibiotalar contact surface area.

a. Lloyd J et al. Revisiting the concept of talar shift in ankle fractures. Foot Ankle Int. 2006 Oct; 27(10):793-6. b. van den Bekerom MP et al. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma. 2009 Jan; 66(1): 279-84.

April 07, 2014

Of the 20,000 known species of spiders that inhabit the United States, only 60 are capable of biting humans. Of those 60, only 4 species (brown recluse, black widow, hobo spider, yellow sac spider) have been known to be dangerous to humans.

Braitberg G, Segal L. Spider Bites – Assessment and Management. Aust Fam Physician. 2009; 38(11): 862-7.

April 06, 2014

Glycemic Control: A quick 15-minute walk after each meal is better for glycemic control than a once-daily 45-minute walk.

a. DiPietro L et al. Three 15-min Bouts of Moderate Postmeal Walking Significantly Improves 24-h Glycemic Control in Older People at Risk for Impaired Glucose Tolerance. Diabetes Care. 2013 Jun 11.

April 05, 2014

Sprinting vs Long Distance Running: Sprinting is better for controlling high blood pressure than long distance running.

a. Buchan DS et al. The effects of time and intensity of exercise on novel and established markers of CVD in adolescent youth. Am J Hum Biol. 2011 Jul-Aug; 23(4):517-26.

April 04, 2014

Pediatric ligaments are stronger and more compliant then adults, thus sprains are less common in young children.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

April 03, 2014

Type II physeal fractures extend through the physis and metaphysis, these are the most common type of physeal fracture.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

April 02, 2014

Bicarb in DKA? Bicarbonate is not recommended to treat DKA unless all other therapy has failed in a life-threatening situation. 

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.

April 01, 2014

Status epilepticus is more responsive to medications when treated early, and becomes less effective over time.

Thomas SH, Handel DA, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: Just the Facts. New York, NY: McGraw-Hill; 2013. Section 10 Pediatrics.