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Critical Care

Is Serum Lactate Necessary in Patients with Normal Anion Gap and Serum Bicarbonate?

Volume 16, Issue 3, May 2015
Daniel Aronovich, DO, et al.

There has been an increase in patients having serum lactate drawn in emergency situations. The objective of this study was to determine whether or not it was necessary to obtain a lactate level in patients with a normal serum bicarbonate level and anion gap. This is a retrospective chart review evaluation of 304 patients who had serum lactate and electrolytes measured in an emergency setting in one academic medical center.

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Treatment Protocol Assessment

Case Series of Patients with Ruptured Abdominal Aortic Aneurysm

Volume 16, Issue 3, May 2015
Taylor Spencer, MD, MPH, et al.

Traditionally, patients with suspected ruptured abdominal aortic aneurysm (rAAA) are taken immediately for operative repair. Computed tomography (CT) has been considered contraindicated. However, with the emergence of endovascular repair, this approach to suspected rAAA could be changing.

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Racial Differences in Opiate Administration for Pain Relief at an Academic Emergency Department

Volume 16, Issue 3, May 2015
R. Myles Dickason, MD, MPH, et al.

The decision to treat pain in the emergency department (ED) is a complex, idiosyncratic process. Prior studies have shown that EDs undertreat pain. Several studies demonstrate an association between analgesia administration and race. This is the first Midwest single institution study to address the question of race and analgesia, in addition to examining the effects of both patient and physician characteristics on race-based disparities in analgesia administration.

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Opioid Education and Nasal Naloxone Rescue Kits in the Emergency Department

Volume 16, Issue 3, May 2015
Kristin Dwyer, MD, et al.

Emergency departments (EDs) may be high-yield venues to address opioid deaths with education on both overdose prevention and appropriate actions in a witnessed overdose. In addition, the ED has the potential to equip patients with nasal naloxone kits as part of this effort. We evaluated the feasibility of an ED-based overdose prevention program and described the overdose risk knowledge, opioid use, overdoses, and overdose responses among participants who received overdose education and naloxone rescue kits (OEN) and participants who received overdose education only (OE).

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Epinephrine for Anaphylaxis: Underutilized and Unavailable

Volume 16, Issue 3, May 2015
Larissa S. Dudley, MD

Anaphylaxis is a rapidly progressing, potentially life threatening allergic reaction that has been increasing in prevalence, most commonly triggered by foods, medications, and insect stings. Allergies in children are increasingly more common. Unfortunately, anaphylactic reactions are under-recognized, due to overlooked or under-appreciated symptoms, and therefore under-treated with epinephrine.1 For several years, epinephrine has been established as the drug of choice for anaphylaxis.2 Even a few minutes delay in the recognition and treatment of anaphylaxis can lead to hypoxia or death. Therefore, healthcare professionals and laypeople alike should be able to recognize the signs and symptoms of anaphylaxis and have accessible resources to initiate treatment.

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Reassessing After-Hour Arrival Patterns and Outcomes in ST-Elevation Myocardial Infarction

Volume 16, Issue 3, May 2015
James Langabeer, PhD, MBA, et al.

Differences in after-hours capability or performance of ST-elevation myocardial infarction (STEMI) centers has the potential to impact outcomes of patients presenting outside of regular hours. Using a prospective observational study, we analyzed all 1,247 non-transfer STEMI patients treated in 15 percutaneous coronary intervention (PCI) facilities in Dallas, Texas, during a 24-month period (2010–2012). Controlling for confounding factors through a variety of statistical techniques, we explored differences in door-to-balloon (D2B) and in-hospital mortality for those presenting on weekends vs. weekdays and business vs. after hours.

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Variability in the Initial Costs of Care and One-Year Outcomes of Observation Services

Volume 16, Issue 3, May 2015
Ibrahim Abbass, RPh, PhD

The use of observation units (OUs) following emergency departments (ED) visits as a model of care has increased exponentially in the last decade. About one-third of U.S. hospitals now have OUs within their facilities. While their use is associated with lower costs and comparable level of care compared to inpatient units, there is a wide variation in OUs characteristics and operational procedures. The objective of this research was to explore the variability in the initial costs of care of placing patients with non-specific chest pain in observation units (OUs) and the one-year outcomes.

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Physician Documentation of Sepsis Syndrome Is Associated with More Aggressive Treatment

Volume 16, Issue 3, May 2015
Lisa R. Stoneking, MD, et al.

Timely recognition and treatment of sepsis improves survival. The objective is to examine the association between recognition of sepsis and timeliness of treatments.Patients whose emergency physicians articulated sepsis syndrome in their documentation or who launched the sepsis order set received antibiotics sooner and received more total volume of fluid.

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Association of Insurance Status with Health Outcomes Following Traumatic Injury: Statewide Multicenter Analysis

Volume 16, Issue 3, May 2015
Vatsal Chikani, MPH, BHMS, et al.

Recognizing disparities in definitive care for traumatic injuries created by insurance status may help reduce the higher risk of trauma-related mortality in this population. Our objective was to understand the relationship between patients’ insurance status and trauma outcomes.We collected data on all patients involved in traumatic injury from eight Level I and 15 Level IV trauma centers, and four non-designated hospitals through Arizona State Trauma Registry between January 1, 2008 and December 31, 2011.

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Diagnostic Acumen

Psychiatric and Medical Management of Marijuana Intoxication in the Emergency Department

Volume 16, Issue 3, May 2015
Quan M. Bui, BS, et al.

We use a case report to describe the acute psychiatric and medical management of marijuana intoxication in the emergency setting. A 34-year-old woman presented with erratic, disruptive behavior and psychotic symptoms after recreational ingestion of edible cannabis. She was also found to have mild hypokalemia and QT interval prolongation.

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Diagnostic Acumen

Pediatric Urinary Retention and Constipation: Vaginal Agenesis with Hematometrocolpos

Volume 16, Issue 3, May 2015
Rebekah Heckmann, MD, et al.

An 11-year-old healthy female presented to the emergency department with three days of worsening suprapubic pain, urinary retention, and constipation. She was afebrile with normal vital signs. Her physical examination was notable for suprapubic distention and bulging pink vaginal tissue at the introitus. Bedside ultrasound suggested a distended bladder.

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Diagnostic Acumen

Rectus Sheath Hematoma: An Unfortunate Consequence of Novel Anticoagulants

Volume 16, Issue 3, May 2015
Kimberly Stillman, DO, et al.

A 76-year-old male presented to the emergency department complaining of intense abdominal pain. He reported one week earlier an upper respiratory illness with violent coughing spells. Past medical history included recent percutaneous coronary intervention for a myocardial infarction 6 months prior where he received three drug-eluting stents and was subsequently discharged home on Prasugrel (Effient) and Aspirin.

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Diagnostic Acumen

Unusual Placement of a Central Venous Catheter: Left Pericardiophrenic Vein

Volume 16, Issue 3, May 2015
Karim El-Kersh, MD, et al.

A 62-year-old man presented to the emergency department with hypotension and diarrhea secondary to Clostridium difficile infection. Due to poor peripheral access, a left internal jugular vein triple lumen central venous catheter (CVC) was inserted for fluid resuscitation. The CVC was placed under real-time ultrasound guidance, which revealed normal anatomy, with no resistance during placement.

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Diagnostic Acumen

Vaginal Bulge

Volume 16, Issue 3, May 2015
Kubwimana M. Mhayamaguru, MD, et al.

A 61-year-old female presented to the emergency department complaining of constipation and vaginal bulge with valsalva 89 days after a robotic-assisted hysterectomy. The patient had intercourse three days prior to presentation and experienced postcoital abdominal discomfort with vaginal bleeding. She denied any other trauma. She had no other complaints and denies fevers, chills, nausea, vomiting, abdominal distension, or constipation. Physical exam revealed exposed bowel protruding through the vaginal cavity.

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Diagnostic Acumen

Rare Radiological Pattern of Diffuse Esophageal Spasm

Volume 16, Issue 3, May 2015
Demis N. Lipe, MD, MSc, et al.

A 42-year-old man with history of esophageal strictures and esophageal dilation presented to the emergency department with 12 hours of dysphagia and non-bloody emesis. His symptoms started upon waking and included sharp retrosternal pain during each attempt at swallowing. Dysphagia occurred with both solids and liquid. He denied difficulty initiating swallowing, pain with eating the previous night, halitosis and hematemesis.

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Diagnostic Acumen

Horner’s Syndrome after Superficial Cervical Plexus Block

Volume 16, Issue 3, May 2015
Stefan Flores, MD, et al.

Ultrasound-guided nerve blocks are becoming more essential for the management of acute pain in the emergency department (ED). With increased block frequency comes unexpected complications that require prompt recognition and treatment. The superficial cervical plexus block (SCPB) has been recently described as a method for ED management of clavicle fracture pain. Horner’s syndrome (HS) is a rare and self-limiting complication of regional anesthesia in neck region such as brachial and cervical plexus blocks.

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Diagnostic Acumen

Emergent Presentation of Decompensated Mitral Valve Prolapse and Atrial Septal Defect

Volume 16, Issue 3, May 2015
Jessie Kang, BSc, et al.

Mitral valve prolapse is not commonly on the list of differential diagnosis when a patient presents in the emergency department (ED) in severe distress, presenting with non-specific features such as abdominal pain, tachycardia and dyspnea. A healthy 55-year-old man without significant past medical history arrived in the ED with a unique presentation of a primary mitral valve prolapse with an atrial septal defect uncommon in cardiology literature. Early recognition of mitral valve prolapse in high-risk patients for severe mitral regurgitation or patients with underlying cardiovascular abnormalities such as an atrial septal defect is crucial to prevent morbid outcomes such as sudden cardiac death.

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Diagnostic Acumen

Anaphylaxis Due to Head Injury

Volume 16, Issue 3, May 2015
Heather C. Bruner, MD, et al.

Both anaphylaxis and head injury are often seen in the emergency department, but they are rarely seen in combination. We present a case of a 30-year-old woman who presented with anaphylaxis with urticaria and angioedema following a minor head injury. The patient responded well to intramuscular epinephrine without further complications or airway compromise. Prior case reports have reported angioedema from hereditary angioedema during dental procedures and maxillofacial surgery, but there have not been any cases of first-time angioedema or anaphylaxis due to head injury.

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Diagnostic Acumen

Morel-Lavallee Lesion Initially Diagnosed as Quadriceps Contusion: Ultrasound, MRI, and Importance of Early Intervention

Volume 16, Issue 3, May 2015
Nicholas A. Weiss, DO, et al.

Morel-Lavallee lesions (MLL) are rare, closed degloving injuries caused by trauma that delivers a shearing force to the soft tissue most commonly of the hip. If not treated in the acute and subacute setting these lesions are often complicated by re-accumulation of fluid, infection, or chronic pain. We present a unique case of a recurrent, massive medial knee/thigh MLL in which proper treatment was delayed due to initial diagnosis of a quadriceps contusion.

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Rapid Diagnosis of Nonconvulsive Status Epilepticus Using Reduced-Lead Electroencephalography

Volume 16, Issue 3, May 2015
Jay M. Brenner, MD, et al.

Electroencephalography (EEG) is indicated for diagnosing nonconvulsive status epilepticus (NCSE) in a patient who has altered level of consciousness after a motor seizure. A study in a neonatal population found 94% sensitivity and 78% specificity for detection of seizure using a single-lead device. This study aims to show that a reduced montage EEG would detect 90% of seizures detected on standard EEG.

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Bleb Point: Mimicker of Pneumothorax in Bullous Lung Disease

Volume 16, Issue 3, May 2015
Christopher Gelabert, MD, et al.

In patients presenting with severe dyspnea, several diagnostic challenges arise in distinguishing the diagnosis of pneumothorax versus several other pulmonary etiologies like bullous lung disease, pneumonia, interstitial lung disease, and acute respiratory distress syndrome. Distinguishing between large pulmonary bullae and pneumothorax is of the utmost importance, as the acute management is very different. While multiple imaging modalities are available, plain radiographs may be inadequate to make the diagnosis and other advanced imaging may be difficult to obtain.

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Diagnosis of a Strangulated Laparoscopic Incisional Hernia with Point-of-Care Ultrasonography

Volume 16, Issue 3, May 2015
Niran Argintaru, MD, et al.

The use of point-of-care ultrasound for the diagnosis of bowel obstructions and hernias is becoming increasingly common in the emergency department (ED). Using a relatively rare case of an incisional port hernia, we demonstrate the ultrasound findings of a strangulated hernia causing a partial small bowel obstruction. A 46-year-old female presented four days following a laparoscopic surgery complaining of abdominal pain, nausea and lack of bowel movements.

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Prehospital Care

Rapid Extrication versus the Kendrick Extrication Device (KED): Comparison of Techniques Used After Motor Vehicle Collisions

Volume 16, Issue 3, May 2015
Joshua Bucher, MD, et al.

This is a small experiment that showed decreased patient neck movement using a KED versus RE but resulted in increased patient movement in obese patients. Further studies are needed to determine if the KED improves any meaningful patient outcomes in the era of increased evidence-based medicine in emergency medical services.

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Prehospital Care

Self-Reported Provider Safety in an Urban Emergency Medical System

Volume 16, Issue 3, May 2015
Molly Furin, MD, MS

No recent data describes the frequency of physical or verbal assaults or which providers have increased fear for their safety. This information may help to guide interventions to improve safety. Our objective was to describe self-reported abuse and perceptions of safety and to determine if there are differences between gender, shift, and years of experience in a busy two-tiered, third service urban EMS system.

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Prehospital Care

Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times

Volume 16, Issue 3, May 2015
Justin C. Stowens, MD, et al.

Brief, early notification of STEMI by paramedics through 9-1-1 dispatchers achieves earlier CCL activation in a hospital system already using EMS-directed CCL activation. This practice significantly decreased DTB and yielded a higher percentage of patients meeting the DTB≤60 minutes quality metric.

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Prehospital Care

Knowledge and Beliefs of EMS Providers toward Lights and Siren Transportation

Volume 16, Issue 3, May 2015
Joseph Tennyson, MD, et al.

The use of warning lights and siren (WLS) increases the risk of ambulance collisions. Multiple studies have failed to demonstrate a clinical benefit to the patients. We sought to investigate the degree to which providers understand the data and incorporate it into their practice.

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: westjem@gmail.com

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WestJEM
ISSN: 1936-900X
e-ISSN: 1936-9018

CPC-EM
ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.