Examining the Timeliness of ST-elevation Myocardial Infarction Transfers

Ward, MJ.

Despite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI.

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Effect of Implementation of HEART Chest Pain Protocol on Emergency Department Disposition, Testing and Cost

Bylund, WE.

Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms.

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More than Just another Pulmonary Embolism

A 25-year-old male presented to the emergency department with 1 week of progressive right-sided chest pain. The pain was sharp, radiated to the back, and worse with deep inspiration. He denied dyspnea and leg pain or swelling.

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Intussusception Status-Post Roux-en-Y Gastric Bypass

A 38-year-old female presented with acute onset epigastric abdominal pain and vomiting. Surgical history included gastric bypass surgery 8 years prior and cesarean delivery. The patient was in severe distress, afebrile, had significant epigastric tenderness with guarding, normal bowel sounds, and no distention or masses.

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Aortocaval Fistula

A 77-year-old Caucasian male with a history of hypertension presented with sudden onset of lower back pain, nausea, and vomiting.

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Pacemaker Limitation of Tachycardia in Hypovolemic Shock

A 49-year-old white man was admitted to the emergency department with nausea and diarrhea of 11 hours duration. He had experienced crampy abdominal pain as well. He reported that his stools had been dark and malodorous. He had no prior history of gastrointestinal disorders, nor travel, unusual oral or liquid intake. There was a remote history of alcohol abuse, but no hepatitis or cirrhosis. Recent alcohol intake was denied by the patient. He had no medical allergies. His past medical history was pertinent for a history of hypertension, congestive heart failure, and a dual chamber pacemaker insertion. There was no history of diabetes mellitus, smoking, or myocardial infarction. Medications included lisinopril, a small dose of aspirin daily, and thyroid supplement. Family history was negative for cardiomyopathy, sudden cardiac death, gastric or duodenal ulcers, colon cancer, or any congenital abnormalities.

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Cardiac Arrest from Postpartum Spontaneous Coronary Artery Dissection

We present the case of a 32-year-old woman who presented to the emergency department with a witnessed cardiac arrest. She was otherwise healthy with no cardiac risk factors and had undergone an uneventful repeated cesarean section 3 days priorly. The patient underwent defibrillation, out of ventricular fibrillation to a perfusing sinus rhythm, and was taken to the catheterization laboratory where coronary angiography findings showed spontaneous dissection of the left anterior descending artery. The patient received a total of 6 stents during her hospital stay and was eventually discharged in good condition. Spontaneous coronary artery dissection is a rare entity with a predilection for pregnant or postpartum women. Early diagnosis and treatment are key for survival, and when identified early, mortality rate is reduced.

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Acute Aortic Dissection in Third Trimester Pregnancy without Risk Factors

Spontaneous aortic dissection in pregnancy is rare and life threatening for both the mother and the fetus. Most commonly, it is associated with connective tissue disorders, cardiac valve variants, or trauma. We present the case of a 23-year-old previously healthy woman, 36 weeks pregnant with a syncopal episode after dyspnea and vomiting. She subsequently developed cardiac arrest and underwent aggressive resuscitation, emergent thoracotomy, and cesarean delivery without recovery. On autopsy, she was found to have an aortic dissection of the ascending aorta. This case is presented to raise awareness and review the literature and the clinical approach to critical care for pregnant patients.

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“Playboy Bunny” Sign of Congestive Heart Failure

In emergency, ultrasound has been widely used as a noninvasive and effective examination to evaluate congestive heart failure. We highlight “Playboy Bunny” sign as a reliable marker and an important clue to the diagnosis of passive hepatic congestion, caused by congestive heart failure.

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Course of Untreated High Blood Pressure in the Emergency Department

No clear understanding exists about the course of a patient’s blood pressure (BP) during an emergency department (ED) visit. Prior investigations have demonstrated that BP can be reduced by removing patients from treatment areas or by placing patients supine and observing them for several hours. However, modern EDs are chaotic and noisy places where patients and their families wait for long periods in an unfamiliar environment. We sought to determine the stability of repeated BP measurements in the ED environment.

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Myocardial Ischemia with Penetrating Thoracic Trauma

Penetrating trauma is a rare cause of myocardial infarction. Our report describes a 47-year-old female who presented with a gunshot wound from a shotgun and had an ST-elevation myocardial infarction. The patient received emergent coronary angiography, which demonstrated no evidence of coronary atherosclerotic disease but did show occlusion of a marginal vessel secondary to a pellet. The patient was managed medically for the myocardial infarction without cardiac sequelae. Patients with penetrating trauma to the chest should be evaluated for myocardial ischemia. Electrocardiography, echocardiography and cardiac angiography play vital roles in evaluating these patients and helping to guide management.

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Dolor de Pecho

A 44-year-old Hispanic male with a history of Wolff-Parkinson-White Syndrome (WPW) presented with chest pain and palpitations that had been constant for three hours.

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Iatrogenic Claudication from a Vascular Closure Device after Cardiac Catheterization

We report a case of iatrogenic claudication as a result of a misplaced percutaneous arterial closure device (PACD) used to obtain hemostasis after cardiac catheterization. The patient presented one week after his procedure with complaints suggestive of right lower extremity claudication. Computed tomographic angiography demonstrated a near total occlusion of the right common femoral artery from a PACD implemented during the cardiac catheterization. The use of PACD’s to obtain rapid hemostasis is estimated to occur in half of all cardiac catheterizations. Ischemic complications as a result of these devices must be considered when evaluating post procedural patients with extremity complaints.

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Frail Patient with Abdominal Pain

Volvulus is a frequent condition in patients presenting in the emergency department (ED) with abdominal pain. While cecal volvulus occurs more often in young patients, sigmoid volvulus is more common in elderly patients.

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Orbital Cellulitis and Abscess

A seven-year-old male presented with fever, left-sided facial redness, swelling and proptosis over a 24-hour period. He had noted left-sided toothache and rhinorrhea over the preceding week. On presentation, he stated that he was unable to see “anything, including light” from his left eye.

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Acute Stroke from Air Embolism After Leg Sclerotherapy

A previously healthy 38-year-old woman, with no significant past medical history, presented to the emergency department with acute onset of weakness after outpatient sclerotherapy. She had two milliliters of 0.5% foamed tetradecylsulfate injected into right lower extremity varicose veins. Twenty minutes after completion of the procedure, she had acute onset of right upper and lower extremity weakness.

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Massive Empyema

A 22-year-old man presented to a rural Ugandan clinic with three months of progressive dyspnea. He described a non-productive cough and subjective fevers and chills. He appears mildly dyspneic but is in no acute distress.

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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.