Review Article Archives - Page 3 of 4 - The Western Journal of Emergency Medicine

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Michael P. Wilson, MD, PhD et al.

The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.

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Utility of the History and Physical Examination in the Detection of Acute Coronary Syndromes in Emergency Department Patients

Zachary DW Dezman, MD, MS, et al.

The purpose of this article was to summarize the findings of recent investigations regarding the ability of various components of the history and physical examination to identify which patients presenting to the ED with chest pain require further investigation for possible ACS.

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The Fast and the Furious: Low-Risk Chest Pain and the Rapid Rule-Out Protocol

Maite Anna Huis in ’t Veld, MD, et al.

Accelerated diagnostic pathways (ADP) have been designed to identify low-risk chest pain patients in the emergency department.

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American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines

Author Affiliation Eric L. Anderson, MD University of Maryland, Department of Psychiatry, College Park, Maryland Kimberly Nordstrom, MD, JD University of Colorado School of Medicine, Department of Psychiatry, Aurora, Colorado; Denver Health Medical Center, Emergency Psychiatry, Denver, Colorado Michael P. Wilson, MD, PhD Department of Emergency Medicine Behavioral Emergencies Research lab, University of Arkansas for […]

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Endemic Infections

Dengue, Zika and Chikungunya: Emerging Arboviruses in the New World

Jessica Patterson, MD et al.

The arboviruses that cause dengue, chikungunya, and Zika illnesses have rapidly expanded across the globe in recent years, with large-scale outbreaks occurring in Western Hemisphere territories in close proximity to the United States (U.S.). In March 2016, the Centers for Disease Control and Protection (CDC) expanded its vector surveillance maps for A. aegypti and A. albopictus, the mosquito vectors for these arboviruses.

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U.S. Food and Drug Administration: Review for the Emergency Physician of Approval Process and Limitations

Nadia Zuabi, BS et al.

Emergency physicians (EP) frequently are exposed to promotion for drugs and devices through professional organizations and meetings, journals, and direct-to-consumer pharmaceutical advertising (DTCPA). To provide optimum patient care through evidence-based medicine, it is critical to be aware of the processes that regulate these drugs.

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Population Health Research Design

Discriminating Between Legitimate and Predatory Open Access Journals: Report from the International Federation for Emergency Medicine Research Committee

Bhakti Hansoti, MBChB, MPH et al.

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The Peregrinating Psychiatric Patient in the Emergency Department

The Peregrinating Psychiatric Patient in the Emergency Department
Scott Simpson, MD, MPH et al.

Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’ intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed.

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Treatment Protocol Assessment

Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm

Volume 17, Issue 4, July 2016
Levi Kitchen, MD et al.

Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objectives of the study is to use current evidence and recommendations to (1) propose a diagnostic algorithm for IC-DVT when definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVT treatment.

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Critical Care

Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016

Volume 17, Issue 3, May 2016
Steve Christos, DO, MS et al.

Anticoagulation is the mainstay of medical treatment, prevention and reduction of recurrent venous thromboembolism, stroke prevention in patients with non-valvular atrial fibrillation, and it reduces the incidence of recurrent ischemic events and death in patients with acute coronary syndrome. Options for anticoagulation have been steadily increasing. Physicians need to be aware of the clinical profile of anticoagulation agents, reversal agents and treatment strategies in the face of major bleeding.

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Survey of Individual and Institutional Risk Associated with the Use of Social Media

Volume 17, Issue 3, May 2016
Manish Garg, MD, et al.

Introduction: Residents and faculty in emergency medicine (EM) residency programs might
be unaware of the professional and legal risks associated with the use of social media (SM).
eScholarship provides open access, scholarly publishing
services to the University of California and delivers a dynamic
research platform to scholars worldwide.
The objective of this study was to identify and characterize the types and reported incidence of
unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal
and institutional risks.
Methods: This multi-site study used an 18-question survey tool that was distributed electronically
to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine
Residency Directors (CORD), and the residents of 14 EM programs during the study period May
to June 2013.
Results: We received 1,314 responses: 772 from residents and 542 from faculty. Both
groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use
by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents
reported posting of one of the following by a resident peer or nursing colleague: identifiable
patient information (26%); or a radiograph, clinical picture or other image (52%). Residents
reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%),
and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by
NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph,
clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted
images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or
inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued
reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were
more likely to post photos of their resident peers or nursing colleagues in an intoxicated state
than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and
identifiable patient information (p=0.0004) than were residents.
Conclusion: EM residents and faculty members cause and encounter HRTPE frequently while
using SM; these events present significant risks to the individuals responsible and their associated
institution. Awareness of these risks should prompt responsible SM use and consideration of
CORD’s Social Media Task Force recommendations.

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Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting

Volume 17, Issue 2, March 2016.
Scott L. Zeller, MD, et al.

Introduction: Patient agitation represents a significant challenge in the emergency department
(ED), a setting in which medical staff are working under pressure dealing with a diverse range of
medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff,
and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time
constraints and limited access to specialist psychiatric support have in the past led to the strategy
of “restrain and sedate,” which was believed to represent the optimal approach; however, it is
increasingly recognized that more patient-centered approaches result in improved outcomes. The
objective of this review is to raise awareness of best practices for the management of agitation in the
ED and to consider the role of new pharmacologic interventions in this setting.
Discussion: The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines
address the complete management of agitation, including triage, diagnosis, interpersonal
calming skills, and medicine choices. Since their publication in 2012, there have been further
developments in pharmacologic approaches for dealing with agitation, including both new agents
and new modes of delivery, which increase the options available for both patients and physicians.
Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/
sublingual and intranasal formulations. To date, the only formulation administered via a nonintramuscular
route with a specific indication for agitation associated with bipolar or schizophrenia
is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have
the potential to improve overall patient experience, thereby improving future cooperation between
patients and healthcare providers.
Conclusion: Management of agitation in the ED should encompass a patient-centered approach,
incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is
necessary, a cooperative approach using non-invasive medications should be employed where
possible.

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Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back

Volume 17, Issue 2, March 2016.
Talayeh Rezayat, DO, MPH, et al.

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark
approach has become less used in comparison to ultrasound (US) guided internal jugular
catheterization due to a higher rate of mechanical complications. A growing body of evidence
indicates that SCV catheterization with real-time US guidance can be accomplished safely and
efficiently. While several cannulation approaches with real-time US guidance have been described,
available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be
preferred. This approach allows for direct visualization of needle advancement, which reduces risk
of complications and improves successful placement. Infraclavicular SCV cannulation requires
simultaneous use of US during needle advancement, but for an inexperienced operator, it is more
easily learned compared to the traditional landmark approach. In this article, we review the evidence
supporting the use of US guidance for SCV catheterization and discuss technical aspects of the
procedure itself.

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Strain Echocardiography in Acute Cardiovascular Diseases

Volume 17, Issue 1, January 2016.
Mark Favot, MD, et al.

Echocardiography has become a critical tool in the evaluation of patients presenting to
the emergency department (ED) with acute cardiovascular diseases and undifferentiated
cardiopulmonary symptoms. New technological advances allow clinicians to accurately measure left
ventricular (LV) strain, a superior marker of LV systolic function compared to traditional measures
such as ejection fraction, but most emergency physicians (EPs) are unfamiliar with this method of
echocardiographic assessment.
This article discusses the application of LV longitudinal strain in the ED and reviews how it has been
used in various disease states including acute heart failure, acute coronary syndromes (ACS) and
pulmonary embolism.
It is important for EPs to understand the utility of technological and software advances in ultrasound
and how new methods can build on traditional two-dimensional and Doppler techniques of
standard echocardiography. The next step in competency development for EP-performed focused
echocardiography is to adopt novel approaches such as strain using speckle-tracking software in
the management of patients with acute cardiovascular disease. With the advent of speckle tracking,
strain image acquisition and interpretation has become semi-automated making it something
that could be routinely added to the sonographic evaluation of patients presenting to the ED with
cardiovascular disease. Once strain imaging is adopted by skilled EPs, focused echocardiography
can be expanded and more direct, phenotype-driven care may be achievable for ED patients with a
variety of conditions including heart failure, ACS and shock.

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Patient Communication

The Need for More Prehospital Research on Language Barriers: A Narrative Review

Volume 16, Issue 7, December 2015.
Ramsey C. Tate, MD, MS

Introduction: Despite evidence from other healthcare settings that language barriers negatively
impact patient outcomes, the literature on language barriers in emergency medical services (EMS)
has not been previously summarized. The objective of this study is to systematically review existing
studies of the impact of language barriers on prehospital emergency care and identify opportunities
for future research.
Methods: A systematic review with narrative synthesis of publications with populations specific to
the prehospital setting and outcome measures specific to language barriers was conducted. A fourprong
search strategy of academic databases (PubMed, Academic Search Complete, and Clinical
Key) through March 2015, web-based search for gray literature, search of citation lists, and review
of key conference proceedings using pre-defined eligibility criteria was used. Language-related
outcomes were categorized and reported as community-specific outcomes, EMS provider-specific
outcomes, patient-specific outcomes, or health system-specific outcomes.
Results: Twenty-two studies met eligibility criteria for review. Ten publications (45%) focused on
community-specific outcomes. Language barriers are perceived as a barrier by minority language
speaking communities to activating EMS. Eleven publications (50%) reported outcomes specific
to EMS providers, with six of these studies focused on EMS dispatch. EMS dispatchers describe
less accurate and delayed dispatch of resources when confronted with language discordant callers,
as well as limitations in the ability to provide medical direction to callers. There is a paucity of
research on EMS treatment and transport decisions, and no studies provided patient-specific or
health system-specific outcomes. Key research gaps include identifying the mechanisms by which
language barriers impact care, the effect of language barriers on EMS utilization and clinically
significant outcomes, and the cost implications of addressing language barriers.
Conclusion: The existing research on prehospital language barriers is largely exploratory, and
substantial gaps in understanding the interaction between language barriers and prehospital care
have yet to be addressed. Future research should be focused on clarifying the clinical and cost
implications of prehospital language barriers.

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Critical Care

The Physiologically Difficult Airway

Volume 16, Issue 7, December 2015.
Jarrod M. Mosier, MD, et al.

Airway management in critically ill patients involves the identification and management of the
potentially difficult airway in order to avoid untoward complications. This focus on difficult airway
management has traditionally referred to identifying anatomic characteristics of the patient that
make either visualizing the glottic opening or placement of the tracheal tube through the vocal
cords difficult. This paper will describe the physiologically difficult airway, in which physiologic
derangements of the patient increase the risk of cardiovascular collapse from airway management.
The four physiologically difficult airways described include hypoxemia, hypotension, severe
metabolic acidosis, and right ventricular failure. The emergency physician should account for
these physiologic derangements with airway management in critically ill patients regardless of the
predicted anatomic difficulty of the intubation.

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Critical Care

Evidence-based Comprehensive Approach to Forearm Arterial Laceration

Volume 16, Issue 7, December 2015.
Janice N. Thai, MD, et al.

Introduction: Penetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or
a complex injury involving other structures including veins, tendons and nerves. The management of
forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution
in management has emerged especially at urban trauma centers, where the multidisciplinary resource
of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of
such injuries. The objective of this review was to provide an evidence-based, systematic, operative
and nonoperative approach to the management of isolated and complex forearm lacerations. A
comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse
did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional
or societal consensus guidelines or best practice guidelines exist to our knowledge.
Discussion: The optimal methods for achieving hemostasis are by a combination approach utilizing
direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure.
While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive
approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations.
Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent
operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has
been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or
tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding,
and perform a complete physical examination of the hand to document the presence or absence of other
associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In
a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without
long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand
specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of
complex injury.
Conclusion: Management in accordance with well-established clinical principles will maximize treatment
efficacy and functional outcome while minimizing the cost of medical care.

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Education Scholarship and its Impact on Emergency Medicine Education

Volume 16, Issue 6, November 2015.
Jonathan Sherbino, MD, MEd

Emergency medicine (EM) education is becoming increasingly challenging as a result of changes
to North American medical education and the growing complexity of EM practice. Education
scholarship (ES) provides a process to develop solutions to these challenges. ES includes both
research and innovation. ES is informed by theory, principles and best practices, is peer reviewed,
and is disseminated and archived for others to use. Digital technologies have improved the
discovery of work that informs ES, broadened the scope and timing of peer review, and provided
new platforms for the dissemination and archiving of innovations. This editorial reviews key steps
in raising an education innovation to the level of scholarship. It also discusses important areas for
EM education scholars to address, which include the following: the delivery of competency-based
medical education programs, the impact of social media on learning, and the redesign of continuing
professional development.

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Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction

Volume 16, Issue 5, September 2015.
Carlos J. Roldan, MD

Despite the level of skill of the operator and the use of ultrasound guidance, central venous catheter
(CVC) placement can result in CVC malpositioning, an unintended placement of the catheter tip in
an inadequate vessel. CVC malpositioning is not a complication of central line insertion; however,
undiagnosed CVC malpositioning can be associated with significant morbidity and mortality. The
objectives of this review were to describe factors associated with intravascular malpositioning of
CVCs inserted via the neck and chest and to offer ways of preventing, identifying, and correcting
such malpositioning. A literature search of PubMed, Cochrane Library, and MD Consult was
performed in June 2014. By searching for “Central line malposition” and then for “Central venous
catheters intravascular malposition,” we found 178 articles written in English. Of those, we found
that 39 were relevant to our objectives and included them in our review. According to those articles,
intravascular CVC malpositioning is associated with the presence of congenital and acquired
anatomical variants, catheter insertion in left thoracic venous system, inappropriate bevel orientation
upon needle insertion, and patient’s body habitus variants. Although plain chest radiography is
the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC
malpositioning even in presence of normal or inconclusive conventional radiography findings should
prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning. With very
few exceptions, the recommendation in cases of intravascular CVC malpositioning is to remove and
relocate the catheter. Knowing the mechanisms of CVC malpositioning and how to prevent, identify,
and correct CVC malpositioning could decrease harm to patients with this condition.

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Critical Care

Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report

Volume 16, Issue 4, July 2015
Kevin Lu, BS, et al.

Missile embolization is regarded as a rare phenomenon in the world of penetrating trauma. While figures in the world of civilian trauma do not exist, there is reason to believe that missile emboli are frequent enough to warrant the attention of any medical decision maker who cares for trauma patients.

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Headache in Pregnancy: An Approach to Emergency Department Evaluation and Management

Volume 16, Issue 2, March 2015
Jessica C. Schoen, MD, MS et al

Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges.

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Jaguar Attack on a Child: Case Report and Literature Review

Volume 16, Issue 2, March 2015
Kenneth V. Iserson, MD, MBA et al.

Jaguar attacks on humans rarely occur in the wild. When they do, they are often fatal. We describe a jaguar attack on a three-year-old girl near her home deep in a remote area of the Guyanese jungle. The patient had a complex but, relatively, rapid transport to a medical treatment facility for her life-threatening injuries. The child, who suffered typical jaguar-inflicted injury patterns and survived, is highlighted. We review jaguar anatomy, environmental status, hunting and killing behaviors, and discuss optimal medical management, given the resource-limited treatment environment of this international emergency medicine case.

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Critical Care

Posterior Reversible Encephalopathy Syndrome in the Emergency Department: Case Series and Literature Review

Volume 16, Issue 1, January 2015
Ryan J. Thompson, MD et al.

Posterior Reversible Encephalopathy Syndrome (PRES) often has variable presentations and causes, with common radiographic features—namely posterior white matter changes on magnetic resonance (MRI). As MRI becomes a more frequently utilized imaging modality in the Emergency Department, PRES will become an entity that the Emergency Physician must be aware of and be able to diagnose.

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Anticoagulation Drug Therapy: A Review

Volume 16, Issue 1, January 2015
Katherine Harter, MD et al.

Historically, most patients who required parenteral anticoagulation received heparin, whereas those patients requiring oral anticoagulation received warfarin. Due to the narrow therapeutic index and need for frequent laboratory monitoring associated with warfarin, there has been a desire to develop newer, more effective anticoagulants.

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Healthcare Utilization

Low-Cost Alternative External Rotation Shoulder Brace and Review of Treatment in Acute Shoulder Dislocations

Volume 16, Issue 1, January 2015
Kyle Lacy, MD, MS et al.

Traumatic dislocations of the shoulder commonly present to emergency departments (EDs). Immediate closed reduction of both anterior and posterior glenohumeral dislocations is recommended and is frequently performed in the ED.

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Emergency Medical Services Public Health Implications and Interim Guidance for the Ebola Virus in the United States

Volume 16, Issue 1, January 2015
Christopher E. McCoy, MD, MPH et al.

The 25th known outbreak of the Ebola Virus Disease (EVD) is now a global public health emergency and the World Health Organization (WHO) has declared the epidemic to be a Public Health Emergency of International Concern (PHEIC). Since the first cases of the West African epidemic were reported in March 2014, there has been an increase in infection rates of over 13,000% over a 6-month period.

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