Fact of the Day - October 2014
Brought to you by the AAEM Resident & Student Association (AAEM/RSA)October 31, 2014
Children with minor head trauma with vomiting as their only symptom do not require a head CT.
Dayan MD, Peter, Holmes MD, James, et.al. Annals of Emergency Medicine. 2014: Volume 63 Page 664
October 30, 2014
Sucrose administered 2 minutes prior to needle related procedure reduces pain associated with the procedure in infants <1 y/o
Michiels MD, Erica Hoyle MD, John. Annals of Emergency Medicine. 2014: Volume 63 Number 3: Pg 300
October 29, 2014
Digoxin serum levels do not necessarily correlate with toxicity. Degree of toxicity should be judged based on symptoms, electrocardiogram findings, and the serum potassium level.
Levine M, O’Conner A. Digitalis (cardiac glycoside) poisoning. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed July 8, 2014)
October 28, 2014
Although uncommon, colchicine toxicity is associated with significant morbidity and mortality. Colchicine overdoses of >0.8 mg/kg have been associated with 100% mortality. Multisystem organ dysfunction can occur 24-36 hours after ingestion, with nonspecific symptoms occurring earlier (nausea, vomiting, diarrhea).
Pandalai SL, Schier JG. Colchicine. AAEM/RSA Toxicology Handbook 2nd Ed. 153-156
October 27, 2014
"I ate a mushroom…" After ingestion of a poisonous mushroom, in general, symptoms occurring soon after the ingestion are a sign of relative safety. Symptoms occurring 5 or more hours after ingestion are an ominous sign for hepatotoxicity. (We still, however, recommend discussing with a poison control center)
Majlesi N, Shih RD. Cyclopeptide-containing Mushrooms. AAEM/RSA Toxicology Handbook 2nd Ed. 161-164.
October 26, 2014
In acetaminophen overdose, remember "150". If the acetaminophen level is >150 (at 4 hours post-ingestion) OR a single acute acetaminophen ingestion is suspected to be >150 mg/kg (or 7.5 grams), then start a 150 mg/kg loading dose of IV acetylcysteine (Acetadote).
Baer AB. Acetaminophen. AAEM/RSA Toxicology Handbook 2nd Ed. Pg 1-4.
October 25, 2014
The old adage "A new LBBB is considered a STEMI equivalent" has changed! The "Sgarbossa criteria" was officially adopted as ECG criteria for diagnosis of STEMI in the setting of a LBBB.
O’Gara PT, Kushner FG, Ascheim DD, Casey DE, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):529-55.
October 24, 2014
The definition of STEMI changed in 2013! The new STEMI definition includes: "New ST elevation at the J-point in at least 2 contiguous leads of ≥2mm in men (≥1.5mm in women) in leads V2-V3 and/or ≥1mm in other contiguous chest or limb leads."
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):529-55.
October 23, 2014
Thrombolysis in Pulmonary Embolism: A recent large meta-analysis comparing thrombolytics with anticoagulant therapy in pulmonary with right ventricular dysfunction demonstrated lower mortality (2.17% vs 3.89%) but a greater risk of major bleeding (9.24% vs 3.42%). In patients 65 years and younger, however, risks of major bleeding were not significantly increased.
Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage: A Meta-analysis. JAMA. 2014;311(23):2414-2421. doi:10.1001/jama.2014.5990.
October 22, 2014
In the United States, 9.8% of all deaths are related to excessive alcohol consumption.
Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of Excessive Alcohol Consumption to Deaths and Years of Potential Life Lost in the United States. Prev Chronic Dis 2014;11:130293. DOI: http://dx.doi.org/10.5888/pcd11.130293
October 21, 2014
Methemoglobinemia (MetHb): At MetHb levels between 25% and 50% symptoms typically include headache, dizziness, dyspnea, or syncope. Pulse oximeters often read approximately 85% with significant methemoglobinemia. Methylene blue is the treatment (1-2mg/kg of 1% solution).
Challoner KR, Nordt SP. Methemoglobinemia. AAEM/RSA Toxicology Handbook 2nd Ed. 261-264.
October 20, 2014
Toxic alcohol poisoning: Methanol and ethylene glycol will typically cause an elevated osmol gap AND an elevated anion gap. Isopropanol causes only an elevated osmol gap.
"Watts DJ, Horrell D. Ethylene Glycol. AAEM/RSA Toxicology Handbook 2nd Ed. 165-168.; Watts DJ, Fumanti BJ. Methanol. AAEM/RSA Toxicology Handbook 2nd Ed. 257-260.; Watts DJ, Bendas C. Isopropyl Alcohol. AAEM/RSA Toxicology Handbook 2nd Ed. 241-244."
October 19, 2014
Immune Reconstitution Inflammatory Syndrome can be seen in AIDS patients who had recently begun Anti-Retroviral Therapy, presentation can include but is not limited to: pulmonary infiltrates, hypoxia, pericarditis, fever/constitutional symptoms, meningeal signs, focal neurologic deficits, abdominal pain, hepatosplenomegaly, and decreased visual acuity.
Beatty G. Immune Reconstitution Inflammatory Syndrome. Emergency Medicine Clinics of North America. 2010 Volume 28, Issue 2, Pages 393-407
October 18, 2014
The use of revascularization procedures in coronary artery stenosis does relieve anginal symptoms; however, it has not consistently reduced the risk of acute coronary syndrome or death.
Libby P. Mechanisms of Acute Coronary Syndromes and Their Implications for Therapy. New England Journal of Medicine. 2013;368:2004-13.
October 17, 2014
High altitude pulmonary edema is a disorder caused by exaggerated pulmonary constriction that leads to high pulmonary artery pressure, these pressures lead to a non-inflammatory capillary leak.
Bartsch P, Swenson E. Acute High-Altitude Illnesses. New England Journal of Medicine. 2013;368:2294-2302.
October 16, 2014
High altitude cerebral edema can present with mild fever, truncal ataxia and decreased consciousness, without appropriate treatment, brain herniation and death can result in 24 hours.
Bartsch P, Swenson E. Acute High-Altitude Illnesses. New England Journal of Medicine. 2013;368:2294-2302.
October 15, 2014
Acute Mountain Sickness presents with symptoms of headaches, anorexia, nausea, dizziness, malaise and/or sleep disturbance; it occurs in 10-25% of people not acclimated who ascend to 2500 meters.
Bartsch P, Swenson E. Acute High-Altitude Illnesses. New England Journal of Medicine. 2013;368:2294-2302.
October 14, 2014
Conservative treatment is effective in 90% of cases of acute osteomyelitis in children.
Peltola H, Paakonen M. Acute Osteomyelitis in Children. New England Journal of Medicine. 2014; 370: 4. 352-360.
October 13, 2014
Osteomyelitis due to MRSA causes greater elevation in WBC count, CRP and ESR than other bacteria.
Peltola H, Paakonen M. Acute Osteomyelitis in Children. New England Journal of Medicine. 2014; 370: 4. 352-360.
October 12, 2014
In addition to its main action of reversing N-acetyl-p-benzoquinone imine (NAPQI) formation, N-acetylcysteine can diminish hepatocyte injury, decrease the incidence of cerebral edema, preserve blood flow to the brain in the incidence of cerebral edema, decrease the need for vasopressors, and decrease overall likelihood of death in acetaminophen overdose.
Hendrickson RG. Chapter 34. Acetaminophen. In: Hendrickson RG, ed. Goldfrank's Toxicologic Emergencies. 9th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=6509959
October 11, 2014
The Rumack-Matthew nomogram, which is used to determine the risk level of acetaminophen overdose, cannot be used in an ingestion of combined acetaminophen/diphenhydramine due to increased time to reach peak levels of acetaminophen toxicity.
Ho S, Arellano M, Zolkowski-Wynne J. Delayed increase in acetaminophen concentration after Tylenol PM overdose. The American Journal Of Emergency Medicine [serial online]. May 1999;17(3):315-317.
October 10, 2014
Within 3 hours, the patient with sepsis needs the following: lactate level measured, blood cultures prior to antibiotic administration, administer broad spectrum antibiotics, and administer 30 mL/kg crystalloid for hypotension of lactate >4.
Dellinger RP, Levy, MM, Rhoades A, et al: Surviving Sepsis Campaign: International Guidlines for Management of Severe Sepsis and Septic Shock: 2012 Critical Care Medicine 2014; 41:580-637
October 09, 2014
Fitz-Hugh-Curtis Syndrome: perihepatitis (capsular adhesions) present in up to 5% PID.
DB Pregerson, Quick Essentials: Emergency Medicine pocketbook, EMresource.org
October 08, 2014
Fitz-Hugh-Curtis Treatment: Start with cefoxitin 2g IV+ Zithromax 1000mg or alternate. Consult GYN. Consider admission
DB Pregerson, Quick Essentials: Emergency Medicine pocketbook, EMresource.org
October 07, 2014
Fitz-Hugh-Curtis Diagnosis by endocervical swab: Chlamydia >Gonorrhea: PCR on cervix better than urine. (Alternative: serum anti-chlamydia Ab titers)
DB Pregerson, Quick Essentials: Emergency Medicine pocketbook, EMresource.org
October 06, 2014
Fitz-Hugh-Curtis Testing: LFTs & US usually normal. D-dimer often elevated. CT w/ IV contrast may show subtle liver capsule enhancement but usually not needed.
DB Pregerson, Quick Essentials: Emergency Medicine pocketbook, EMresource.org
October 05, 2014
Fitz-Hugh-Curtis Clinical Exam: RUQ/rib pain (often pleuritic) greater than pelvic pain. Tender RUQ/R ribs, pelvic exam often normal.
DB Pregerson, Quick Essentials: Emergency Medicine pocketbook, EMresource.org
October 04, 2014
Although penicillin "allergy" is the most common drug-class "allergy" reported in US medical records, most people (approximately 95%) with this history are actually not allergic and tolerate future penicillin use. Subjects with a penicillin “allergy” history are exposed to significantly more antibiotics, are associated with increased hospital stay, and have increased C. difficile, MRSA, and VRE prevalence.
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.
October 03, 2014
The most common place disk batteries become lodged, resulting in clinical sequelae, is the esophagus. Batteries that successfully traverse the esophagus are unlikely to lodge at any other location. Esophageal damage can occur in a relatively short period of time (2-2.5 h) when a disk battery is lodged in the esophagus. Liquefaction necrosis may occur because sodium hydroxide is generated by the current produced by the battery. Perforation has occurred as rapidly as 6 hours after ingestion.
Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. Jun 2010;125(6):1168-77. [Medline].
October 02, 2014
Measles spreads through the air when an infected person coughs or sneezes. It is so contagious that if one person has it, 90% of the people around him or her will also become infected if they are not protected. For every 1,000 children who get measles, one or two will die.
Measles (Rubeola). Centers for Disease Control and Prevention. http://www.cdc.gov/measles/about/overview.html. Accessed June 25, 2014.
October 01, 2014
Persons at increased risk for infection or serious complications from salmonellosis (e.g., children aged <5 years and immunocompromised persons) should avoid contact with reptiles and amphibians and any items that have been in contact with reptiles and amphibians. CDC recommends that reptiles and amphibians should be kept out of households that include children aged <5 years or immunocompromised persons.
Reptiles. Healthy Pets Healthy People. Pets. Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). Division of Global Migration and Quarantine (DGMQ). http://www.cdc.gov/healthypets/pets/reptiles.html. Accessed: June 25, 2014.
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