The Birth of the Western Journal of Emergency Medicine: WestJEM

This editorial describes the rational for the transformation of the California Journal of Emergency Medicine to the Western Journal of Emergency Medicine, and lays out its new mission, vision and focus

Supraglottic Laryngeal Mass

[WestJEM. 2009;10(4):298-299.

Excited Delirium

Excited (or agitated) delirium is characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. It is typically associated with the use of drugs that alter dopamine processing, hyperthermia, and, most notably, sometimes with death of the affected person in the custody of law enforcement. Subjects typically die from cardiopulmonary arrest, although the cause is debated. Unfortunately an adequate treatment plan has yet to be established, in part due to the fact that most patients die before hospital arrival. While there is still much to be discovered about the pathophysiology and treatment, it is hoped that this extensive review will provide both police and medical personnel with the information necessary to recognize and respond appropriately to excited delirium

The Use of Bedside Ultrasound in Cardiac Arrest

BACKGROUND: The decision to terminate resuscitative measures in the setting of cardiac arrest is based on several criteria, some of which are subjective. Ultrasound in the emergency department has potentially added an objective data point to assist in this decision. OBJECTIVE: We sought to determine if emergency physicians who were trained in the use of ultrasound use it in cardiac arrest scenarios and if so, what effect they believe it has on the duration of the resuscitative event. Our hypothesis was that emergency physicians terminate resuscitative efforts sooner with visualization of cardiac standstill and feel more comfortable in doing so. METHODS: The ultrasound training program at Los Angeles County + University of Southern California Medical Center began in 1995. We surveyed all graduates of the residency program since that date about their use of ultrasound in cardiac arrest. RESULTS: Surveys were mailed to 154 practicing emergency physicians. One hundred and sixteen surveys (75%) surveys were returned. During residency, the majority of individuals (68%) reported that they had used ultrasound during at least 10 cardiac arrests. It was used to search for a reversible cause of cardiac arrest (pericardial effusion) or for documentation of cardiac standstill. Ninety-one percent of individuals used the ultrasound result as an aid in deciding when to terminate resuscitative efforts and 59% believed it shortened their resuscitation time. After graduation, only 53% of individuals in this study have ultrasound available in their daily clinical practice. For these individuals, 60% use it in more than 50% of their cardiac arrest situations. Ultrasound was used to shorten the code time (63%) as well as to reassure and confirm the presence of cardiac standstill for the physician (88%) and the resuscitation team (59%). CONCLUSION: Most emergency physicians in this cohort who have access to ultrasound use it in cardiac arrest cases and believe that it shortens code times

Loss of Digits after Trauma in a Patient with Systemic Lupus Erythematosus

A 19-year-old female with Systemic Lupus Erythematosus (SLE) presented with ischemia of her left hand following trauma. Medical therapy was initiated but failed to improve her symptoms, and revision amputation was ultimately performed. The patient’s final diagnosis was digital ischemia due to secondary Raynaud’s Phenomenon (RP). The authors discuss diagnosis, complications, and treatment of this relatively uncommon disorder. The authors report this case in order to discuss how secondary RP can be complicated by ischemia and the multidisciplinary approach that needs to take place to prevent the latter from occurring

Asthma: Effect of genotype on Response to Therapy in the Emergency Department

Objective: We examined the effect of two β2-adrenoreceptor (β2AR) polymorphisms (A46G and C79G) in asthmatics presenting to the Emergency Department (ED) in relation to their response to standard therapy measured by change in Forced Expiratory Volume at one second (FEV1). Our hypothesis was that the polymorphisms in the β2AR gene would predict clinical response to therapy with 46G and 79C displaying decreased response to inhaled therapy. Methods: This was a pilot feasibility study of a convenience sample of patients seen in the ED for acute exacerbation of asthma. Baseline data collected included: age, gender, ethnicity, vital signs, baseline FEV1, body mass index (BMI), smoking history and medications taken prior to arrival to the ED. Patients received standard ED care and FEV1 was measured after each treatment. Blood was taken and genotyped. Results: Fifty-three patients were enrolled over a three-month period. Using mean improvement in FEV1 from baseline to the first treatment as the primary outcome of interest, we performed multivariable linear regression analyses, with the FEV1 change as the dependent variable. When modeled as an ordinal covariate representing the number of G alleles present, there was a significant positive trend for the C79G locus (p=0.035). Those who were GG homozygotes had a 0.284 L/min improvement in FEV1 (31%) after their initial albuterol treatment compared to 0.123 L/min (12%) in those who were CC homozygotes. This represents a 2.5 times relative difference and a 19% actual difference. Genotypes at the A46G locus were not associated with FEV1 change. Conclusion: In this pilot study of ED patients with acute asthma exacerbation, there was a significant effect of genotype on response to therapy

Use of the Trendelenburg Position in the Porcine Model Improves Carotid Flow During Cardiopulmonary Resuscitation

BACKGROUND: Cardiopulmonary resuscitation (CPR) is now widely used as a treatment for ventricular fibrillation, though numerous studies have shown the outcome of standard CPR to be dismal. Alternative methods of CPR, including interposed abdominal compression, constant aortic occlusion, and the use of intrathoracic pressure regulator, have been shown to increase cardiac output and affect the mortality rate of CPR.OBJECTIVES: Here we suggest the Trendelenburg position as yet another method of increasing cardiac output and therefore improving the effectiveness of chest compressions. We hypothesized that the use of the Trendelenburg position during CPR would increase cardiac output as measured by carotid blood flow.METHODS: We anaesthetized six pigs and measured their pre-arrest carotid flow rate for two minutes. We then induced ventricular fibrillation in those pigs and performed open-chest CPR on them. Post-arrest carotid blood flow was measured for two minutes each at 0 (supine position), 10, 20, and 30 degrees of head-down tilt in each pig. The mean carotid flow for each degree of tilt was compared to mean carotid flow at 0 degrees of tilt using a paired student t-test.RESULTS: We found an increase of up to 1.4-fold in carotid blood flow during CPR in the Trendelenburg position, though only 20 and 30 degrees of Trendelenburg showed a statistically significant increase from the 0 degrees of tilt in pigs.CONCLUSION: The Trendelenburg position can lead to increased blood flow through the carotid arteries during CPR in this pig model. Future studies should investigate whether this increased blood flow through the carotid arteries leads to improved brain perfusion and better neurologic outcomes