Two Cases of Anti-NMDA Receptor Encephalitis

Two Cases of Anti-NMDA Receptor Encephalitis
Jesse Baker, BA, et al.

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a form of autoimmune encephalitis with prominent neuropsychiatric features. Patients present with acute psychosis, memory impairment, dyskinesias, seizures, and/or speech disorders. The clinical course is often complicated by respiratory failure, requiring intubation. Approximately half of patients are found to have an associated ovarian tumor, which expresses NMDAR. Recognition of anti-NMDAR encephalitis by emergency physicians is essential in order to initiate early treatment and avoid psychiatric misdiagnosis. The disease is highly treatable with tumor removal and immunosuppression, and most patients demonstrate a full recovery. In this case series, we report two cases of anti-NMDAR encephalitis in adult women in the United States and provide a review of the literature.

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A Curious Case of Right Upper Quadrant Abdominal Pain

A Curious Case of Right Upper Quadrant Abdominal Pain
Andrew Grock, MD et al.

An otherwise healthy 36-year-old man presented with sudden-onset right upper quadrant abdominal pain and vomiting. A bedside ultrasound, performed to evaluate hepatobiliary pathology, revealed a normal gallbladder but free intraperitoneal fluid. After an expedited CT and emergent explorative laparotomy, the patient was diagnosed with a small bowel obstruction with ischemia secondary to midgut volvulus. Though midgut volvulus is rare in adults, delays in definitive diagnosis and management can result in bowel necrosis. Importantly, an emergency physician must be able to recognize bedside ultrasound findings associated with acutely dangerous intrabdominal pathology.

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Prehospital Care

The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval

The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval
Megan H. Halliday, MSIII, BS et al.

A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time.

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Reaching Out of the Box: Effective Emergency Care Requires Looking Outside the Emergency Department

Volume 17, Issue 4, July 2016
Dr. Daniel Dworkis, MD, PhD, et al.

Patients do not start to exist when they arrive at the door of our emergency departments (ED), nor do they stop existing when they leave. Instead, before they fall ill or become injured they live and exist somewhere and when they are discharged from our care they will likely return to that same somewhere. As emergency providers (EPs), our attention must be focused on the patients in front of us, but fundamentally the details of this “somewhere” directly affect our ability to provide safe and effective emergency care. Specifically, both patient-specific factors like homelessness, immigration status, living situation, or insurance coverage, and structural factors arising from broader community and societal forces like food deserts, community violence, and poor housing quality can strongly impact both emergency presentations and our ability to safely and effectively discharge patients. Here, we argue that our duty as EPs extends beyond the four walls of our EDs into life in our communities, and that understanding and addressing the unique strengths and needs of the communities we serve is a crucial component of our ability to provide effective emergency care.

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ACE-I Angioedema: Accurate Clinical Diagnosis May Prevent Epinephrine-Induced Harm

Volume 17, Issue 3, May 2016
R. Mason Curtis, MD et al.

Introduction: Upper airway angioedema is a life-threatening emergency department (ED)
presentation with increasing incidence. Angiotensin-converting enzyme inhibitor induced
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angioedema (AAE) is a non-mast cell mediated etiology of angioedema. Accurate diagnosis by
clinical examination can optimize patient management and reduce morbidity from inappropriate
treatment with epinephrine. The aim of this study is to describe the incidence of angioedema
subtypes and the management of AAE. We evaluate the appropriateness of treatments and
highlight preventable iatrogenic morbidity.
Methods: We conducted a retrospective chart review of consecutive angioedema patients
presenting to two tertiary care EDs between July 2007 and March 2012.
Results: Of 1,702 medical records screened, 527 were included. The cause of angioedema
was identified in 48.8% (n=257) of cases. The most common identifiable etiology was AAE
(33.1%, n=85), with a 60.0% male predominance. The most common AAE management strategies
included diphenhydramine (63.5%, n=54), corticosteroids (50.6%, n=43) and ranitidine (31.8%,
n=27). Epinephrine was administered in 21.2% (n=18) of AAE patients, five of whom received
repeated doses. Four AAE patients required admission (4.7%) and one required endotracheal
intubation. Epinephrine induced morbidity in two patients, causing myocardial ischemia or
dysrhythmia shortly after administration.
Conclusion: AAE is the most common identifiable etiology of angioedema and can be accurately
diagnosed by physical examination. It is easily confused with anaphylaxis and mismanaged with
antihistamines, corticosteroids and epinephrine. There is little physiologic rationale for epinephrine
use in AAE and much risk. Improved clinical differentiation of mast cell and non-mast cell mediated
angioedema can optimize patient management.

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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


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

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.