A case is presented of simultaneous uvulitis and epiglottitis in an afebrile patient without elev... more A case is presented of simultaneous uvulitis and epiglottitis in an afebrile patient without elevation in the white blood cell count. This case is reported to illustrate the need for a high index of suspicion for the rare association of uvulitis and epiglottitis.
To assess the need for antibiotics in low-risk human bite wounds, a prospective, double-blind, pl... more To assess the need for antibiotics in low-risk human bite wounds, a prospective, double-blind, placebo-controlled study involving 127 patients presenting with low-risk human bite wounds over 2 years to a 40,000 visit per year major academic ED was performed. Low-risk bites penetrated only the epidermis and did not involve hands, feet, skin, overlying joints, or cartilaginous structures. Exclusion criteria included age less than 18 years, puncture wounds, immunocompromise, allergy to penicillin or related compound, or bites greater than 24 hours old. Patients were randomly assigned to receive either a cephalexin/penicillin combination or placebo. One hundred twenty-five patients completed the study. Infection developed in 1 of 62 patients receiving placebo (1.6%, 95% confidence interval CI, 0-7.3%). Infection developed in 0 of 63 patients receiving the cephalexin/penicillin combination (0%, 95% CI, 0-4.6%). Antibiotic treatment of some low-risk human bite wound could be unnecessary. Infection rates appear similar in low-risk human bite wounds whether treated with antibiotics or placebo.
A 6-month prospective study was performed to examine the efficacy and safety of a rapid-sequence ... more A 6-month prospective study was performed to examine the efficacy and safety of a rapid-sequence nebulized metaproterenol regimen for the treatment of acute asthma in adults. Patients 18 years of age or older who were not pregnant and who had not received l~2-agonist therapy were identified and started on a rapid-sequence metaproterenol regimen (15 mg) by the triage nurse. Pretreatment and posttreatment peak flow, respiratory rate, pulse rate, and blood pressure were documented. Patients also gave a pretreatment and posttreatment rating of the clinical severity of their attack using a 1-to-10 visual analogue scale. Fifty patients were entered into the study, with an average age of 38 years (range, 19 to 87 years). Data were analyzed using the Wilcoxon matched-pairs signed rank test. Patients showed statistically significant increases in peak flow (193 to 328 I./min, P < .00001) and systolic blood pressure (136 to 143 mm Hg, P < .0054). Statistically significant decreases were shown for respiratory rate (25 to 22 beats/min, P < .0001) and clinical severity (6.2 to 3.2, P < .00001). Thirty-three patients (71%) who completed the protocol experienced an increase in pulse rate. Ten (21%) had a pulse rate increase of more than 30 beats/min. Two (4.2%) had pulse rate increases of more than 40 beats/min. Four patients were removed after one or two nebulizers because of severe side effects. One patient's pulse rate increased to more than 200 beats/min. Although effective in reversing bronchospasm, the side effects of metaproterenol when used in rapid sequence are of major concern.
Allergic reactions to insect stings are a common and sometimes serious medical problem. Although ... more Allergic reactions to insect stings are a common and sometimes serious medical problem. Although most reactions to stinging insects are mild, a pool of individuals in the general population has experienced or will manifest an anaphylactic reaction to stings. Concern has been heightened with the introduction of stinging species not indigenous to the United States which have a proclivity for stinging frequently. The emergency physician needs to understand the pathophysiology of insect sting anaphylaxis, recognize its onset, and formulate an appropriate pharmacological treatment plan. In addition, the emergency physician must instruct the patient on avoidance of insects and on outpatient use of epinephrine. For the patient who truly has had an anaphylactic event, referral to an allergist is imperative.
As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of th... more As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of the past year. Without their generous contributions of time and expertise to the peer-review process, the Journal would not be able to advance its mission of emphasizing practical, efficient, and world-class emergency care. The top section editors and reviewers are chosen based on their quality of work, number of assignments, and timeliness of reviews.
We performed a prospective study over a 6-month period to test the efficacy and safety of a conti... more We performed a prospective study over a 6-month period to test the efficacy and safety of a continuous nebulized albuterol protocol for the treatment of acute adult asthma attacks. All patients 18 years or older presenting to the emergency department with acute asthma attacks were begun by the triage nurse on the protocol of three continuous albuterol (2.5 mg) nebulizer treatments. Pretreatment and posttreatment peak flow, respiratory rate, pulse, and blood pressure were documented and patients gave a pretreatment and posttreatment rating of the clinical severity of their attack using a (1 to 10) visual analog scale. In addition, all adverse effects were noted. Seventy-six patients were entered in the study. The average age was 44 years (range, 20 to 82 years). Pretreatment and posttreatment peak flow, respiratory rate, pulse, blood pressure, and clinical severity were compared using the paired t test. Patients showed statistically significant increases in peak flow (128 to 292; P &lt; .0001) and statistically significant decreases in respiratory rate (27 to 20; P &lt; .0001); pulse, 103 to 94 (P &lt; .0001); clinical severity, 7.8/10 to 1.8/10 (P &lt; .0001); and blood pressure, 141/82 to 132/77 (P &lt; .001). Adverse effects were minimal. Two patients (2.6%) felt flushed, three patients (4%) felt jittery, and one patient (1.3%) had a sensation of palpitations. We conclude that a continuous nebulized albuterol protocol is both extremely efficacious and safe for the treatment of acute adult asthma attacks.
Objectives: To study whether emergency department (ED) visits by male patients wane simultaneousl... more Objectives: To study whether emergency department (ED) visits by male patients wane simultaneously with the play of scheduled professional and college sports events. Methods: Retrospective cohort analysis looked at ED male patient registration rates during a time block lasting from two hours before, during, and two hours after the play of professional football games (Monday night, Sundays, post-season play), major league baseball, and a Division I college football and basketball team, respectively. These registration rates were compared to rates at similar times on similar days of the week during the year devoid of a major sporting contest. Games were assumed to have a play time of three hours. Data was collected from April 2000 through March 2003 at an urban academic ED seeing 33,000 male patients above the age of 18 years annually. Results: A total of 782 games were identified and used for purposes of the study. Professional football game dates had a mean of 17.9 males (95% confid...
Objective: This study sought to characterize national patterns for opioid pain medication (OPM) p... more Objective: This study sought to characterize national patterns for opioid pain medication (OPM) prescriptions received during emergency medical encounters in the Veterans Health Administration (VA).Design: The authors conducted a retrospective study of all emergency department (ED) visits by adults in the VA between January 2009 and June 2015. We examined demographics, comorbidities, utilization measures, diagnoses, and prescriptions.Main Outcome Measures: The percentage of ED visits that culminated in the receipt of a prescription for an OPM.Results: There were 6,721,134 emergency medical visits by 1,708,545 individuals during the study period. An OPM was prescribed during 913,872 visits (13.6 percent), and 407,408 individuals (27.5 percent) received at least one OPM prescription. Prescriptions for OPMs peaked in 2011 at 14.5 percent, declining to 12.3 percent in 2015. The percentage of prescriptions limited to 12 pills increased from 25.0 to 32.4 percent. The heaviest users (top 1...
The purpose of the study was to measure national prescribing patterns for hydrocodone/ acetaminop... more The purpose of the study was to measure national prescribing patterns for hydrocodone/ acetaminophen among veterans seeking emergency medical care, and to see if patterns have changed since this medication became a Schedule II controlled substance. Methods: We conducted a retrospective cohort study of emergency department (ED) visits within the Veterans Health Administration (VA) between January 2009 and June 2015. We looked at demographics, comorbidities, utilization measures, diagnoses, and prescriptions. Results: During the study period, 1,709,545 individuals participated in 6,270,742 ED visits and received 471,221 prescriptions for hydrocodone/acetaminophen (7.5% of all visits). The most common diagnosis associated with a prescription was back pain. Prescriptions peaked at 80,776 in 2011 (8.7% of visits), and declined to 35,031 (5.6%) during the first half of 2015 (r=-0.99, p<0.001). The percentage of hydrocodone/acetaminophen prescriptions limited to 12 pills increased from 22% (13,949) in 2009 to 31% (11,026) in the first half of 2015. A prescription was more likely written for patients with a pain score≥7 (OR 3.199, CI [3.192-3.205]), a musculoskeletal (OR 1.622, CI [1.615-1.630]) or soft tissue (OR 1.656, CI [1.649-1.664]) diagnosis, and those below the first quartile for total ED visits (OR 1.282, CI [1.271-1.293]) and total outpatient ICD 9 codes (OR 1.843, CI [1.833-1.853]). Conclusion: Hydrocodone/acetaminophen is the most frequently prescribed ED medication in the VA. The rate of prescribing has decreased since 2011, with the rate of decline remaining unchanged after it was classified as a Schedule II controlled substance. The proportion of prescriptions falling within designated guidelines has increased but is not at goal. [
A quick and accurate diagnosis of maladies affecting the central nervous system (CNS) is imperati... more A quick and accurate diagnosis of maladies affecting the central nervous system (CNS) is imperative. Procurement and analysis of cerebrospinal fluid (CSF) are paramount in helping the clinician determine a patient's clinical condition. Various staining methods, measurement of white blood cell counts, glucose and protein levels, recognition of xanthochromia, and microbiologic studies are CSF parameters that are collectively important in the ultimate determination by a clinician of the presence or absence of a catastrophic CNS condition. Many of these CNS parameters have significant limitations that should be recognized to minimize under treating patients with catastrophic illness.
Methods Clinical Evidence search and appraisal August 2005. In addition, the authors searched the... more Methods Clinical Evidence search and appraisal August 2005. In addition, the authors searched the Web of Science (Science Citation Index to October 2001). The following databases were used to identify studies for this systematic review: Medline 1966 to February 2007, Embase 1980 to February 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 1. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and National Institute for Health and Clinical Excellence (NICE). We also searched for retractions of studies included in the Review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined cri...
Pelvic fractures are associated with significant morbidity and mortality. Despite advances in eme... more Pelvic fractures are associated with significant morbidity and mortality. Despite advances in emergency, radiologic, surgical, and ICU care that have improved survival during the past decade, the morbidity and the mortality remain significantly high [1]. The incidence of pelvic fractures in the United States is estimated to be more than 100,000 per year [2]. Motor vehicle collisions are the most common cause of pelvic fractures [3]. Nine percent of blunt abdominal trauma patients have pelvic fractures, with a mortality rate approaching 50% when associated with hemodynamic instability [4]. This article focuses on the recent developments in the initial management of pelvic fractures, including the use of external pelvic binders, radiographic imaging, interventional radiology, and operative management including the newer use of the technique of preperitoneal packing.
In the expanding search for recreation, we spend more and more of our time in various environment... more In the expanding search for recreation, we spend more and more of our time in various environments. Whether the air is thin or compressed or smoke-filled or there is no air at all, emergency physicians continue to meet and treat the various pulmonary emergencies that the environment may create. The authors present the background, diagnosis, and management of a few of the more common pulmonary emergencies that the environment may produce.
Although the diving community attempts to train and educate its members with regard to the danger... more Although the diving community attempts to train and educate its members with regard to the dangers of the deep, there are still a significant number of individuals each year who need treatment for painful and life-threatening illness incurred as a result of the dive. The emergency physician needs to identify these individuals quickly, stabilize them, and refer and transport as soon as possible to a recompression chamber.
Filoviruses, including Ebola virus, are associated with outbreaks of severe febrile illness with ... more Filoviruses, including Ebola virus, are associated with outbreaks of severe febrile illness with high fatality rates in humans. The 2014 outbreak of Ebola virus in West Africa is by far the largest outbreak in history and the first to spread to highly populated urban areas. The potential for such an epidemic to spread beyond Africa through international travel has raised concern in the world community as well as in American and international health agencies. This article presents background information, personal and public protective strategies, and treatment recommendations for emergency physicians.
A case is presented of simultaneous uvulitis and epiglottitis in an afebrile patient without elev... more A case is presented of simultaneous uvulitis and epiglottitis in an afebrile patient without elevation in the white blood cell count. This case is reported to illustrate the need for a high index of suspicion for the rare association of uvulitis and epiglottitis.
To assess the need for antibiotics in low-risk human bite wounds, a prospective, double-blind, pl... more To assess the need for antibiotics in low-risk human bite wounds, a prospective, double-blind, placebo-controlled study involving 127 patients presenting with low-risk human bite wounds over 2 years to a 40,000 visit per year major academic ED was performed. Low-risk bites penetrated only the epidermis and did not involve hands, feet, skin, overlying joints, or cartilaginous structures. Exclusion criteria included age less than 18 years, puncture wounds, immunocompromise, allergy to penicillin or related compound, or bites greater than 24 hours old. Patients were randomly assigned to receive either a cephalexin/penicillin combination or placebo. One hundred twenty-five patients completed the study. Infection developed in 1 of 62 patients receiving placebo (1.6%, 95% confidence interval CI, 0-7.3%). Infection developed in 0 of 63 patients receiving the cephalexin/penicillin combination (0%, 95% CI, 0-4.6%). Antibiotic treatment of some low-risk human bite wound could be unnecessary. Infection rates appear similar in low-risk human bite wounds whether treated with antibiotics or placebo.
A 6-month prospective study was performed to examine the efficacy and safety of a rapid-sequence ... more A 6-month prospective study was performed to examine the efficacy and safety of a rapid-sequence nebulized metaproterenol regimen for the treatment of acute asthma in adults. Patients 18 years of age or older who were not pregnant and who had not received l~2-agonist therapy were identified and started on a rapid-sequence metaproterenol regimen (15 mg) by the triage nurse. Pretreatment and posttreatment peak flow, respiratory rate, pulse rate, and blood pressure were documented. Patients also gave a pretreatment and posttreatment rating of the clinical severity of their attack using a 1-to-10 visual analogue scale. Fifty patients were entered into the study, with an average age of 38 years (range, 19 to 87 years). Data were analyzed using the Wilcoxon matched-pairs signed rank test. Patients showed statistically significant increases in peak flow (193 to 328 I./min, P < .00001) and systolic blood pressure (136 to 143 mm Hg, P < .0054). Statistically significant decreases were shown for respiratory rate (25 to 22 beats/min, P < .0001) and clinical severity (6.2 to 3.2, P < .00001). Thirty-three patients (71%) who completed the protocol experienced an increase in pulse rate. Ten (21%) had a pulse rate increase of more than 30 beats/min. Two (4.2%) had pulse rate increases of more than 40 beats/min. Four patients were removed after one or two nebulizers because of severe side effects. One patient's pulse rate increased to more than 200 beats/min. Although effective in reversing bronchospasm, the side effects of metaproterenol when used in rapid sequence are of major concern.
Allergic reactions to insect stings are a common and sometimes serious medical problem. Although ... more Allergic reactions to insect stings are a common and sometimes serious medical problem. Although most reactions to stinging insects are mild, a pool of individuals in the general population has experienced or will manifest an anaphylactic reaction to stings. Concern has been heightened with the introduction of stinging species not indigenous to the United States which have a proclivity for stinging frequently. The emergency physician needs to understand the pathophysiology of insect sting anaphylaxis, recognize its onset, and formulate an appropriate pharmacological treatment plan. In addition, the emergency physician must instruct the patient on avoidance of insects and on outpatient use of epinephrine. For the patient who truly has had an anaphylactic event, referral to an allergist is imperative.
As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of th... more As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of the past year. Without their generous contributions of time and expertise to the peer-review process, the Journal would not be able to advance its mission of emphasizing practical, efficient, and world-class emergency care. The top section editors and reviewers are chosen based on their quality of work, number of assignments, and timeliness of reviews.
We performed a prospective study over a 6-month period to test the efficacy and safety of a conti... more We performed a prospective study over a 6-month period to test the efficacy and safety of a continuous nebulized albuterol protocol for the treatment of acute adult asthma attacks. All patients 18 years or older presenting to the emergency department with acute asthma attacks were begun by the triage nurse on the protocol of three continuous albuterol (2.5 mg) nebulizer treatments. Pretreatment and posttreatment peak flow, respiratory rate, pulse, and blood pressure were documented and patients gave a pretreatment and posttreatment rating of the clinical severity of their attack using a (1 to 10) visual analog scale. In addition, all adverse effects were noted. Seventy-six patients were entered in the study. The average age was 44 years (range, 20 to 82 years). Pretreatment and posttreatment peak flow, respiratory rate, pulse, blood pressure, and clinical severity were compared using the paired t test. Patients showed statistically significant increases in peak flow (128 to 292; P &lt; .0001) and statistically significant decreases in respiratory rate (27 to 20; P &lt; .0001); pulse, 103 to 94 (P &lt; .0001); clinical severity, 7.8/10 to 1.8/10 (P &lt; .0001); and blood pressure, 141/82 to 132/77 (P &lt; .001). Adverse effects were minimal. Two patients (2.6%) felt flushed, three patients (4%) felt jittery, and one patient (1.3%) had a sensation of palpitations. We conclude that a continuous nebulized albuterol protocol is both extremely efficacious and safe for the treatment of acute adult asthma attacks.
Objectives: To study whether emergency department (ED) visits by male patients wane simultaneousl... more Objectives: To study whether emergency department (ED) visits by male patients wane simultaneously with the play of scheduled professional and college sports events. Methods: Retrospective cohort analysis looked at ED male patient registration rates during a time block lasting from two hours before, during, and two hours after the play of professional football games (Monday night, Sundays, post-season play), major league baseball, and a Division I college football and basketball team, respectively. These registration rates were compared to rates at similar times on similar days of the week during the year devoid of a major sporting contest. Games were assumed to have a play time of three hours. Data was collected from April 2000 through March 2003 at an urban academic ED seeing 33,000 male patients above the age of 18 years annually. Results: A total of 782 games were identified and used for purposes of the study. Professional football game dates had a mean of 17.9 males (95% confid...
Objective: This study sought to characterize national patterns for opioid pain medication (OPM) p... more Objective: This study sought to characterize national patterns for opioid pain medication (OPM) prescriptions received during emergency medical encounters in the Veterans Health Administration (VA).Design: The authors conducted a retrospective study of all emergency department (ED) visits by adults in the VA between January 2009 and June 2015. We examined demographics, comorbidities, utilization measures, diagnoses, and prescriptions.Main Outcome Measures: The percentage of ED visits that culminated in the receipt of a prescription for an OPM.Results: There were 6,721,134 emergency medical visits by 1,708,545 individuals during the study period. An OPM was prescribed during 913,872 visits (13.6 percent), and 407,408 individuals (27.5 percent) received at least one OPM prescription. Prescriptions for OPMs peaked in 2011 at 14.5 percent, declining to 12.3 percent in 2015. The percentage of prescriptions limited to 12 pills increased from 25.0 to 32.4 percent. The heaviest users (top 1...
The purpose of the study was to measure national prescribing patterns for hydrocodone/ acetaminop... more The purpose of the study was to measure national prescribing patterns for hydrocodone/ acetaminophen among veterans seeking emergency medical care, and to see if patterns have changed since this medication became a Schedule II controlled substance. Methods: We conducted a retrospective cohort study of emergency department (ED) visits within the Veterans Health Administration (VA) between January 2009 and June 2015. We looked at demographics, comorbidities, utilization measures, diagnoses, and prescriptions. Results: During the study period, 1,709,545 individuals participated in 6,270,742 ED visits and received 471,221 prescriptions for hydrocodone/acetaminophen (7.5% of all visits). The most common diagnosis associated with a prescription was back pain. Prescriptions peaked at 80,776 in 2011 (8.7% of visits), and declined to 35,031 (5.6%) during the first half of 2015 (r=-0.99, p<0.001). The percentage of hydrocodone/acetaminophen prescriptions limited to 12 pills increased from 22% (13,949) in 2009 to 31% (11,026) in the first half of 2015. A prescription was more likely written for patients with a pain score≥7 (OR 3.199, CI [3.192-3.205]), a musculoskeletal (OR 1.622, CI [1.615-1.630]) or soft tissue (OR 1.656, CI [1.649-1.664]) diagnosis, and those below the first quartile for total ED visits (OR 1.282, CI [1.271-1.293]) and total outpatient ICD 9 codes (OR 1.843, CI [1.833-1.853]). Conclusion: Hydrocodone/acetaminophen is the most frequently prescribed ED medication in the VA. The rate of prescribing has decreased since 2011, with the rate of decline remaining unchanged after it was classified as a Schedule II controlled substance. The proportion of prescriptions falling within designated guidelines has increased but is not at goal. [
A quick and accurate diagnosis of maladies affecting the central nervous system (CNS) is imperati... more A quick and accurate diagnosis of maladies affecting the central nervous system (CNS) is imperative. Procurement and analysis of cerebrospinal fluid (CSF) are paramount in helping the clinician determine a patient's clinical condition. Various staining methods, measurement of white blood cell counts, glucose and protein levels, recognition of xanthochromia, and microbiologic studies are CSF parameters that are collectively important in the ultimate determination by a clinician of the presence or absence of a catastrophic CNS condition. Many of these CNS parameters have significant limitations that should be recognized to minimize under treating patients with catastrophic illness.
Methods Clinical Evidence search and appraisal August 2005. In addition, the authors searched the... more Methods Clinical Evidence search and appraisal August 2005. In addition, the authors searched the Web of Science (Science Citation Index to October 2001). The following databases were used to identify studies for this systematic review: Medline 1966 to February 2007, Embase 1980 to February 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 1. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and National Institute for Health and Clinical Excellence (NICE). We also searched for retractions of studies included in the Review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined cri...
Pelvic fractures are associated with significant morbidity and mortality. Despite advances in eme... more Pelvic fractures are associated with significant morbidity and mortality. Despite advances in emergency, radiologic, surgical, and ICU care that have improved survival during the past decade, the morbidity and the mortality remain significantly high [1]. The incidence of pelvic fractures in the United States is estimated to be more than 100,000 per year [2]. Motor vehicle collisions are the most common cause of pelvic fractures [3]. Nine percent of blunt abdominal trauma patients have pelvic fractures, with a mortality rate approaching 50% when associated with hemodynamic instability [4]. This article focuses on the recent developments in the initial management of pelvic fractures, including the use of external pelvic binders, radiographic imaging, interventional radiology, and operative management including the newer use of the technique of preperitoneal packing.
In the expanding search for recreation, we spend more and more of our time in various environment... more In the expanding search for recreation, we spend more and more of our time in various environments. Whether the air is thin or compressed or smoke-filled or there is no air at all, emergency physicians continue to meet and treat the various pulmonary emergencies that the environment may create. The authors present the background, diagnosis, and management of a few of the more common pulmonary emergencies that the environment may produce.
Although the diving community attempts to train and educate its members with regard to the danger... more Although the diving community attempts to train and educate its members with regard to the dangers of the deep, there are still a significant number of individuals each year who need treatment for painful and life-threatening illness incurred as a result of the dive. The emergency physician needs to identify these individuals quickly, stabilize them, and refer and transport as soon as possible to a recompression chamber.
Filoviruses, including Ebola virus, are associated with outbreaks of severe febrile illness with ... more Filoviruses, including Ebola virus, are associated with outbreaks of severe febrile illness with high fatality rates in humans. The 2014 outbreak of Ebola virus in West Africa is by far the largest outbreak in history and the first to spread to highly populated urban areas. The potential for such an epidemic to spread beyond Africa through international travel has raised concern in the world community as well as in American and international health agencies. This article presents background information, personal and public protective strategies, and treatment recommendations for emergency physicians.
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