The Western Journal of Emergency Medicine

Online ISSN: 1936-9018
Print ISSN: 1936-900X
Traumatic brain injury (TBI) can be complicated among older adults due to age-related frailty, a greater prevalence of chronic conditions and the use of anticoagulants. We conducted this study using the latest available, nationally-representative emergency department (ED) data to characterize visits for TBI among older adults. We used the 2006-2008 National Hospital Ambulatory Medical Care - Emergency Department (NHAMCS-ED) data to examine ED visits for TBI among older adults. Population-level estimates of triage immediacy, receipt of a head computed tomography (CT) and/or head magnetic resonance imaging (MRI), and hospital admission by type were used to characterize 1,561 sample visits, stratified by age <65 and ≥65 years of age. Of ED visits made by persons ≥65 years of age, 29.1% required attention from a physician within 15 minutes of arrival; 82.1% required a head CT, and 20.9% required hospitalization. Persons ≥65 years of age were 3 times more likely to receive a head CT or MRI compared to younger patients presenting with TBI (adjusted odds ratio [aOR] 3.2; 95% confidence interval [CI], 1.8-5.8), and were 4 times more likely to be admitted to an intensive care unit, step-down unit, or surgery (aOR 4.1; 95% CI 2.1-8.0) compared to younger patients presenting with TBI, while controlling for sex and race. Results demonstrate increased emergent service delivery for older persons presenting with TBI. As the United States population ages and continues to grow, TBI will become an even more important public health issue that will place a greater demand on the healthcare system.
Number of emergency department clinicians reporting on patients with information in the health information exchange by hospital system (HS). HS1 is academic hospital. Others are community hospitals. 
Interventions and Medicaid allowable charges avoided. 
Reduction in Medicare-Allowable Reimbursements per emergency department patient with information in the Health Information Exchange by hospital system (HS). HS1 is academic hospital. Others are community hospitals. 
Use clinician perceptions to estimate the impact of a health information exchange (HIE) on emergency department (ED) care at four major hospital systems (HS) within a region. Use survey data provided by ED clinicians to estimate reduction in Medicare-allowable reimbursements (MARs) resulting from use of an HIE. We conducted the study during a one-year period beginning in February 2012. Study sites included eleven EDs operated by four major HS in the region of a mid-sized Southeastern city, including one academic ED, five community hospital EDs, four free-standing EDs and 1 ED/Chest Pain Center (CPC) all of which participated in an HIE. The study design was observational, prospective using a voluntary, anonymous, online survey. Eligible participants included attending emergency physicians, residents, and mid-level providers (PA & NP). Survey items asked clinicians whether information obtained from the HIE changed resource use while caring for patients at the study sites and used branching logic to ascertain specific types of services avoided including laboratory/microbiology, radiology, consultations, and hospital admissions. Additional items asked how use of the HIE affected quality of care and length of stay. The survey was automated using a survey construction tool (REDCap Survey Software © 2010 Vanderbilt University). We calculated avoided MARs by multiplying the numbers and types of services reported to have been avoided. Average cost of an admission from the ED was based on direct cost trends for ED admissions within the region. During the 12-month study period we had 325,740 patient encounters and 7,525 logons to the HIE (utilization rate of 2.3%) by 231 ED clinicians practicing at the study sites. We collected 621 surveys representing 8.25% of logons of which 532 (85.7% of surveys) reported on patients who had information available in the HIE. Within this group the following services and MARs were reported to have been avoided [type of service: number of services; MARs]: Laboratory/Microbiology:187; $2,073, Radiology: 298; $475,840, Consultations: 61; $6,461, Hospital Admissions: 56; $551,282. Grand total of MARs avoided: $1,035,654; average $1,947 per patient who had information available in the HIE (Range: $1,491 - $2,395 between HS). Changes in management other than avoidance of a service were reported by 32.2% of participants. Participants stated that quality of care was improved for 89% of patients with information in the HIE. Eighty-two percent of participants reported that valuable time was saved with a mean time saved of 105 minutes. Observational data provided by ED clinicians practicing at eleven EDs in a mid-sized Southeastern city showed an average reduction in MARs of $1,947 per patient who had information available in an HIE. The majority of reduced MARs were due to avoided radiology studies and hospital admissions. Over 80% of participants reported that quality of care was improved and valuable time was saved.
Persons with chronic or recurrent pain frequently visit the emergency department (ED), yet little research examines this experience. We conducted this national survey to assess patients' ED experiences. We developed and conducted a ten-minute telephone survey using random digit dial methodology. We included adults with chronic or recurrent pain reporting an ED visit within two years. We interviewed 500 adults. Sixty percent were female, their median age was 54, two-thirds were under a physician's care, and 14% were uninsured. They reported an average of 4.2 ED visits within the past two years. Almost one-half reported "complete" or "a great deal" of pain relief during the ED visit, while 78% endorsed as "somewhat or definitely true" that "the ED staff understood how to treat my pain." Although over three-fourths of patients felt that receiving additional information on pain management or referrals to specialists was "extremely" or "very" important, only one-half reported receiving such referrals or information. A significant minority (11%) reported that the "ED staff made me feel like I was just seeking drugs." The majority (76%) were "somewhat" to "completely satisfied" with their treatment while 24% were "neutral" to "completely dissatisfied". In multivariate models, age, recurrent pain, waiting time, imaging, receiving analgesics and pain relief predicted patient satisfaction. Although those with chronic or recurrent pain report relatively high satisfaction with the ED, our findings suggests that specific areas, such as unmet needs for information and specialty referral, might be targeted to improve care.
As solid organ transplants become more common, recipients present more frequently to the emergency department (ED) for care. We performed a retrospective medical record review of ED visits of all patients who received an organ transplant at our medical center from 2000-2004, and included all visits following the patients' transplant surgery through December 2005 or until failed graft, lost to follow up, or death. Clinically relevant demographic variables, confounding and outcome variables were recorded. Kidney, liver and combined kidney with other organ transplant recipients were included. Five hundred ninety-three patients received kidney (395), liver (161), or combined renal (37) organ transplants during the study period, resulting in 1,251 ED visits. This represents 3.15 ED visits/patient followed over a mean of 30.8 months. Abdominal pain/gastrointestinal (GI) symptoms (31.3%) and infectious complaints (16.7%) were the most common presentations. The most common ED discharge diagnoses were fever/infection (36%), GI/Genitourinary (GU) pathology (20.4%) and dehydration (15%). Renal transplant recipients were diagnosed with infectious processes most often, despite time elapsed from transplant. Liver transplant patients had diagnoses of fever/infection most often in their first 30 days post transplant. Thereafter they were more likely to develop GI/GU pathology. After the first year of transplantation, cardiopulmonary and musculoskeletal pathology become more common in all transplant organ groups. Of the 1,251 ED visits, 762 (60.9%) resulted in hospitalization. Chief complaints of abdominal pain/GI symptoms, infectious complaints, cardiovascular and neurologic symptoms, and abnormal laboratory studies were significantly likely to result in hospitalization. This study demonstrates a significant utilization of the ED by transplant recipients, presenting with a wide variety of symptoms and diagnoses, and with a high hospitalization rate. As the transplant-recipient population grows, these complex patients continue to present diagnostic and treatment challenges to primary care and emergency physicians.
This coronal T2 weighted magnetic resonance image of the patient demonstrates a normal homogenous right undescended testicle (small arrow) and a heterogeneous inflamed left undescended testicle (large arrow).
This coronal T1 weighted magnetic resonance image of the patient demonstrates a normal homogenous right undescended testicle (small arrow) and a heterogeneous inflamed left undescended testicle (large arrow).
Transverse color Doppler image of the patient's right testicle demonstrates uniform echogenicity and flow throughout the testicle.
This transverse color Doppler image of the patient's left testicle demonstrates heterogenous echogenicity and no flow throughout the testicle.
Etiologies of limp by age in toddlers and children.
In this report, we discuss a case of a 14-month-old male presenting in the emergency department with refusal to bear weight on his left leg. Plain radiographic studies revealed no evidence of effusion, fracture, or dislocation. Laboratory studies were significant for an elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Further studies included unremarkable ultrasound of the left hip and normal magnetic resonance imaging (MRI) of both hips. An incidental finding on MRI was a left inguinal mass concerning an incarcerated hernia. Ultrasound of this mass demonstrated a left undescended testis within the inguinal canal and possible incarcerated paratesticular inguinal hernia. The final pathologic diagnosis of a torsed gangrenous left testicle within the inguinal canal was confirmed during surgery.
Fundoscopic examination of the right eye. 
Fundoscopic examination of the left eye. 
Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
Injury collision involvement ratio per 100,000 people annually by age group and sex, Orange County, California, 1998–2007.
Driver fatality ratio per 100,000 people annually by age group, Orange County, California, 1998–2007.
Type of movement preceding collision in nonfreeway collisions by driver age, Orange County, California, 1998–2007.
Injury collision involvement ratio per 100,000 people annually by age group and calendar year, Orange County, California, 1998–2007.
Highest degree of injury by driver age, Orange County, California, 1998–2007.
Introduction: Injuries and fatalities in adult drivers 18–65 years of age have decreased in recent years due to safer vehicles, enhanced medical policies, and implementation of injury prevention policies. However, adult drivers over 65 years of age are continuing to suffer from motor vehicle collision-related injuries and fatalities at a more constant rate. A number of physiological factors contribute to the deterioration in visual acuity, slower reaction speeds, and decreased awareness in older drivers. The objective of this study was to examine injury severity and fatality rates in older drivers compared to their younger counterparts in Orange County, California. Methods: This study used the Statewide Integrated Traffic Record System data for Orange County for the years 1998–2007. Drivers were categorized into 4 age groups: 25–64, 65–74, 75–84, and older than 85 years of age. Injury severity was assessed by the investigating officer. Results: Of the 197,814 drivers involved in motor vehicle collisions, 178,481 (90.2%) were in the 25–64 age group; 11,397 (5.8%) were 65–74; 6,592 (3.3%) were 75–84; and 1,344 drivers (0.7%) were over 85. Those aged 25–64 had the lowest fatality rate per 100,000 people, 2.5, whereas those 75–84 had the highest fatality rate, 4.9. The percent of crashes involving a left turn increased with age, and the percent that were stopped in the road decreases with age. Change in injury collision involvement ratio in the 3 younger age groups decreased by 26% to 32%, but decreased by 18% among drivers aged 85 years and older. Conclusion: The decrease in collision fatalities was greater in the 25–64-year-old group compared to the older adult population. This disparity highlights the need for further injury prevention efforts for older drivers.
Trends of unintentional and intentional poisoning mortalities by racial group per 100,000 persons, United States 2003–2007.
Characteristics of unintentional and intentional poisoning injury mortalities, United States, 2003–2007.
Percentage changes in deaths and rates per 100,000 overall and for each year in unintentional and intentional poisoning mortality by sex—United States, 2003–2007.
Percent change in unintentional and intentional poisoning mortality of males and females by cause, race, and age (United States, 2003–2007)a.
Poisoning, specifically unintentional poisoning, is a major public health problem in the United States (U.S.). Published literature that presents epidemiology of all forms of poisoning mortalities (i.e., unintentional, suicide, homicide) together is limited. This report presents data and summarizes the evidence on poisoning mortality by demographic and geographic characteristics to describe the burden of poisoning mortality and the differences among sub-populations in the U.S. for a 5-year period. Using mortality data from the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, we presented the age-specific and age-adjusted unintentional and intentional (suicide, homicide) poisoning mortality rates by sex, age, race, and state of residence for the most recent years (2003-2007) of available data. Annual percentage changes in deaths and rates were calculated, and linear regression using natural log were used for time-trend analysis. There were 121,367 (rate=8.18 per 100,000) unintentional poisoning deaths. Overall, the unintentional poisoning mortality rate increased by 46.9%, from 6.7 per 100,000 in 2003 to 9.8 per100.000 in 2007, with the highest mortality rate among those aged 40-59 (rate=15.36), males (rate=11.02) and whites (rate=8.68). New Mexico (rate=18.2) had the highest rate. Unintentional poisoning mortality rate increased significantly among both sexes, and all racial groups except blacks (p<0.05 time-related trend for rate). Among a total of 29,469 (rate=1.97) suicidal poisoning deaths, the rate increased by 9.9%, from 1.9 per 100,000 in 2003 to 2.1 per 100,000 in 2007, with the highest rate among those aged 40-59 (rate=3.92), males (rate=2.20) and whites (rate=2.24). Nevada (rate=3.9) had the highest rate. Mortality rate increased significantly among females and whites only (p<0.05 time-related trend for rate). There were 463 (rate=0.03) homicidal poisoning deaths and the rate remained the same during 2003-2007. The highest rates were among aged 0-19 (rate=0.05), males (rate=0.04) and blacks (rate=0.06). Prevention efforts for poisoning mortalities, especially unintentional poisoning, should be developed, implemented and strengthened. Differences exist in poisoning mortality by age, sex, location, and these findings underscore the urgency of addressing this public health burden as this epidemic continues to grow in the U.S.
This study seeks to evaluate the practice patterns of current combined emergency medicine/internal medicine (EM/IM) residents during their training and compare them to the typical practice patterns of EM/IM graduates. We further seek to characterize how these current residents perceive the EM/IM physician's niche. This is a multi-institution, cross-sectional, survey-based cohort study. Between June 2008 and July 2008, all 112 residents of the 11 EM/IM programs listed by the Accreditation Council for Graduate Medical Education were contacted and asked to complete a survey concerning plans for certification, fellowship, and practice setting. The adjusted response rate was 71%. All respondents anticipated certifying in both specialties, with 47% intending to pursue fellowships. Most residents (97%) allotted time to both EM and IM, with a median time of 70% and 30%, respectively. Concerning academic medicine, 81% indicated intent to practice academic medicine, and 96% planned to allocate at least 10% of their future time to a university/academic setting. In evaluating satisfaction, 94% were (1) satisfied with their residency choice, (2) believed that a combined residency will advance their career, and (3) would repeat a combined residency if given the opportunity. Current EM/IM residents were very content with their training and the overwhelming majority of residents plan to devote time to the practice of academic medicine. Relative to the practice patterns previously observed in EM/IM graduates, the current residents are more inclined toward pursuing fellowships and practicing both specialties.
The 2006 field triage decision scheme. Footnote: Reproduced with permission from Morbidity and Mortality Weekly Report. Jan 23, 2009;58. 10  
Adoption status of the 2006 field triage guidelines by state as of April 2010.  
When emergency medical services (EMS) providers respond to the scene of an injury, they must decide where to transport the injured patients for further evaluation and treatment. This is done through a process known as "field triage", whereby a patient's injuries are matched to the most appropriate hospital. In 2005-2006 the National Expert Panel on Field Triage, convened by the Centers for Disease Control and Prevention and the National Highway Traffic Safety Administration, revised the 1999 American College of Surgeons Committee on Trauma Field Triage Decision Scheme. This revision, the 2006 Field Triage Decision Scheme, was published in 2006. State Public Health departments' and EMS' external websites were evaluated to ascertain the current status of implementation of the 2006 Field Triage Decision Scheme. Information regarding field triage was located for 41 states. In nine states no information regarding field triage was available on their websites. Of the 41 states where information was located, seven were classified as "full adopters" of the 2006 Field Triage Decision Scheme; nine were considered "partial adopters"; 17 states were found to be using a full version or modification of the 1999 Field Triage Decision Scheme; and eight states were considered to be using a different protocol or scheme for field triage. Many states have adopted the 2006 Decision Scheme (full or partial). Further investigation is needed to determine the reasons why some states do not adopt the guidelines.
Ambulance response times in Santa Barbara County for 2006 are analyzed using point process techniques, including kernel intensity estimates and K-functions. Clusters of calls result in significantly higher response times, and this effect is quantified. In particular, calls preceded by other calls within 20 km and within the previous hour are significantly more likely to result in violations. This effect appears to be especially pronounced within semi-rural neighborhoods.[WestJEM. 2009;10:42-47.]
Demographic and psychosocial correlates of suicidal attempt among U.S. high school students, 2007 
Demographic and psychosocial correlates of suicidal attempt requiring medical care among U.S. high school students, 2007 
The current study examines the associations between a range of risk factors and reports of suicide attempts and attempts requiring medical care in a nationally representative study of high school students. The goal is to examine sex differences in the risk factors associated with suicide attempts and attempt-related injuries requiring treatment by a health-care provider. We used data from the 2007 Youth Risk Behavior Survey for students in grades 9-12 to assess the prevalence and risk factors for suicidal behavior, as well as differences in these for boys and girls. Cross-sectional multivariate logistic regression analyses were computed to determine the most important risk factors for suicide attempts and for suicide attempts requiring medical care for the sample overall and also stratified for boys and for girls. Overall, 6.9% of adolescents attempted suicide (9.3% of girls versus 4.6% of boys). Girls were more likely than boys to report a suicide attempt in the past year (Adj.OR=2.89). Among girls, sadness (Adj.OR=5.74), weapon carrying (Adj.OR=1.48), dating violence (Adj.OR=1.60), forced sex (Adj.OR=1.72), and huffing glue (Adj.OR=2.04) were significantly associated with suicide attempts. Among boys, sadness (Adj.OR=10.96), weapon carrying (Adj.OR=1.66), forced sex (Adj.OR=2.60), huffing glue (OR=1.63), hard drug use (Adj.OR=2.18), and sports involvement (Adj.OR=1.52) were significantly associated with suicide attempts. These findings demonstrate similarities and differences in the modifiable risk factors that increase risk for suicide attempts among boys and girls. In terms of the differences between boys and girls, hard drug use and sports involvement may be important factors for suicide-prevention strategies directed specifically towards boys, while dating violence victimization may be an important risk factor to address for girls. Overall, these findings can help guide prevention, clinical practice, and intervention strategies to prevent suicidal behaviors among adolescents.
Specialty choice by comfort level. 
Applicants to residency face a number of difficult questions during the interview process, one of which is when a program asks for a commitment to rank the program highly. The regulations governing the National Resident Matching Program (NRMP) match explicitly forbid any residency programs asking for a commitment. We conducted a cross-sectional survey of applicants from U.S. medical schools to five specialties during the 2006-2007 interview season using the Electronic Residency Application Service of the Association of American Medical Colleges. Applicants were asked to recall being asked to provide any sort of commitment (verbal or otherwise) to rank a program highly. Surveys were sent after rank lists were submitted, but before match day. We analyzed data using descriptive statistics and logistic regression. There were 7,028 unique responses out of 11,983 surveys sent for a response rate of 58.6%. Of those who identified their specialty (emergency medicine, internal medicine, obstetrics and gynecology [OBGYN], general surgery and orthopedics), there were 6,303 unique responders. Overall 19.6% (1380/7028) of all respondents were asked to commit to a program. Orthopedics had the highest overall prevalence at 28.9% (372/474), followed by OBGYN (23.7%; 180/759), general surgery (21.7%; 190/876), internal medicine (18.3%; 601/3278), and finally, emergency medicine (15.4%; 141/916). Of those responding, 38.4% stated such questions made them less likely to rank the program. Applicants to residencies are being asked questions expressly forbidden by the NRMP. Among the five specialties surveyed, orthopedics and OBGYN had the highest incidence of this violation. Asking for a commitment makes applicants less likely to rank a program highly.
Reliable and accurate Web-based health information is extremely valuable when applied to emergency medical diagnoses. With this update we seek to build upon on the 2004 study by determining whether the completeness and accuracy of emergency medical information available online has improved over time. The top 15 healthcare information sites, as determined by internet traffic, were reviewed between February 4, 2008, and February 29, 2008. Standard checklists were created from information provided by American Stroke Association, American Heart Association, National Institutes of Health, and American College of Emergency Physicians to evaluate medical content on each of the Web sites for 4 common emergency department diagnoses: myocardial infarct, stroke, influenza, and febrile child. Each Web site was evaluated for descriptive information, completeness, and accuracy. Data were sorted for total medical checklist items, certification and credentialing, and medical items by topic. Three of the 15 sites were excluded because of a lack of medical information on the selected topics. Completeness of sites ranged from 46% to 80% of total checklist items found. The median percentage of items found was 72. Two sites, MSN Health and Yahoo!Health, contained the greatest amount of medical information, with 98 of 123 checklist items found for each site. All Web sites but 1,, contained greater than 50% of aggregated checklist items, and the majority (ie, 7 of 12) contained greater than 70%. was the least complete Web site, containing 57 of 123 items. No significant correlation was found between credentialing and completeness of site (correlation coefficient = -0.385) or credentialing and site popularity (correlation coefficient = 0.184). This study indicates that the completeness and accuracy of online emergency medical information available to the general public has improved over the past 6 years. Overall, health Web sites studied contained greater than 70% of aggregated medical information on 4 common emergency department diagnoses, and 4 sites examined advanced from 2002 to 2008.
Key current American College of Emergency Medicine (ACEP) and Centers for Disease Control and Prevention (CDC) guidance in emergency department (ED) management for novel influenza A (H1N1) in 2009. 
List of antibiotic treatment for community-acquired pneumonia in emergency department in 19 admitted patients with a clinical diagnosis of influenza during 2009 novel H1N1 epidemic. 
Figure. Weekly number of adult emergency department patients given a diagnosis of influenza from May 2008 to December 2009 at Johns Hopkins Hospital. CDC, Center for Disease Control and Prevention; ACEP, American College of Emergency Physicians  
Little is known regarding compliance with management guidelines for epidemic influenza in adult emergency department (ED) settings during the 2009 novel influenza A (H1N1) epidemic, especially in relation to the Centers for Disease Control and Prevention (CDC) guidance. We investigated all patients with a clinical diagnosis of influenza at an inner-city tertiary academic adult ED with an annual census of approximately 60,000 visits from May 2008 to December 2009. We aimed to determine patterns of presentation and management for adult patients with an ED diagnosis of influenza during the H1N1 pandemic, using seasonal influenza (pre-H1N1) as reference and to determine the ED provider's adherence to American College of Emergency Physicians and CDC guidance during the 2009 H1N1 influenza pandemic. Adherence to key elements of CDC 2009 H1N1 guidance was defined as (1) the proportion of admitted patients who were recommended to receive testing or treatment who actually received testing for influenza or treatment with antivirals; and (2) the proportion of high-risk patients who were supposed to be treated who actually were treated with antivirals. Among 339 patients with clinically diagnosed influenza, 88% occurred during the H1N1 pandemic. Patients were similarly managed during both phases. Median length of visit (pre-H1N1: 385 min, H1N1: 355 min, P > 0.05) and admission rates (pre-H1N1: 8%, H1N1: 11%, P > 0.05) were similar between the 2 groups. 28% of patients in the pre-H1N1 group and 16% of patients in the H1N1 group were prescribed antibiotics during their ED visits (P > 0.05). There were 34 admitted patients during the pandemic;, 30 (88%) of them received influenza testing in the ED, and 22 (65%) were prescribed antivirals in the ED. Noticeably, 19 (56%) of the 34 admitted patients, including 6 with a positive influenza test, received antibiotic treatment during their ED stay. During the recent H1N1 pandemic, most admitted patients received ED diagnostic testing corresponding to the current recommended guidance. Antibiotic treatment for ED patients admitted with suspected influenza is not uncommon. However, less than 70% of admitted patients and less than 50% of high-risk patients were treated with antivirals during their ED visit, indicating a specific call for closer adherence to guidelines in future influenza pandemics.
To be honest, I thought this would be a lost cause. Even after skipping a New Drugs and Devices essay in 2012, I figured that I would have to search long and hard to find 10 new things that emergency practitioners needed to know about. Although there were no true blockbuster medications for emergency physicians, I nonetheless found 10 medicines that we probably should know, along with a new device that may change the way we work up patients with palpitations, and a clever new delivery system for subcutaneous epinephrine.
Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review. We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis. Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied. While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.
Multivariate model of factors associated with hospitalization of MVC patients treated in emergency departments by age, United States 2003-2007. 
To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.). We analyzed ED visits for MVCs using data from the 2003-2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years) and younger (18-64 years) MVC patients and calculated odds ratios (OR) and 95% confidence intervals (CIs) to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults. From 2003-2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6-8.3) visits per 1,000 for older adults and 16.4 (95% CI 14.0-18.8) visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46-9.36). Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76-2.86), have a high triage acuity (OR 1.56; 95% CI 0.77-3.14), or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42-2.23) as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8-19.2) of older MVC patients and 6.1% (95% CI 4.8-7.5) of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71-4.43), and admission to the ICU if hospitalized (OR 6.9, 95% CI 0.9-51.9), after adjustment for gender, race, ethnicity, and injury acuity. Markers of injury acuity studied included EMS arrival, high triage acuity category, ED imaging, and diagnosis of a head, spinal cord or internal injury. Although ED visits after MVC for older adults are less common per capita, older adults are more commonly admitted to the hospital and ICU. Older MVC victims require significant ED resources in terms of diagnostic imaging as compared to younger MVC patients. As the U.S. population ages, and as older adults continue to drive, EDs will have to allocate appropriate resources and develop diagnostic and treatment protocols to care for the increased volume of older adult MVC victims.
Distribution of shock index values in the United States and European Union DCLHb clinical trials at all time points by treatment. DCLHb, diasprin crosslinked hemoglobin; NS, normal saline  
Shock index distribution at study entry and after 120 minutes of resuscitation.  
Mean shock index over time by treatment group in the United States and European Union diaspirin cross-linked hemoglobinclinical trials. SI, shock index; DCLHb, diasprin crosslinked hemoglobin; NS, normal saline  
To assess the ability of the shock index (SI) to predict 28-day mortality in traumatic hemorrhagic shock patients treated in the diaspirin cross-linked hemoglobin (DCLHb) resuscitation clinical trials. We used data from two parallel DCLHb traumatic hemorrhagic shock efficacy trials, one in U.S. emergency departments, and one in the European Union prehospital setting to assess the relationship between SI values and 28-day mortality. In the 219 patients, the mean age was 37 years, 64% sustained a blunt injury, 48% received DCLHb, 36% died, and 88% had an SI≥1.0 at study entry. The percentage of patients with an SI≥1.0 dropped by 57% (88 to 38%) from the time of study entry to 120 minutes after study resuscitation (p<0.001). Patients with a SI≥1.0, 1.4, and 1.8 at any time point were 2.3, 2.7, and 3.1 times, respectively, more likely to die by 28 days than were patients with SI values below these cutoffs (p<0.001). Similarly, after 120 minutes of resuscitation, patients with a SI≥1.0 were 3.9× times more likely to die by 28 days (40 vs. 15%, p<0.001). Although the distribution of SI values differed based on treatment group, the receiver operator characeristics data showed no difference in SI predictive ability for 28-day mortality in patients treated with DCLHb. In these traumatic hemorrhagic shock patients, the shock index correlates with 28-day mortality, with higher SI values indicating greater mortality risk. Although DCLHb treatment did alter the distribution of SI values, it did not influence the ability of the SI to predict 28-day mortality.
Ultrasound image of common carotid diameter measurement obtained within 0.5 cm of the carotid bulb and measured intima to intima.
Ultrasound image of common carotid Doppler waveform and velocity time integral measurement acquired with an insonation angle of 58 degrees. The upper spectral waveform tracing (hollow arrow) represents peak flow velocity and the lower spectral waveform (solid arrow) represents mean flow velocity. Plus signs on the spectral waveform represent peak systolic velocity and end diastolic velocity. 
Percent successful completion of ultrasound performance measures. I-bars represent 95% confidence intervals. N = 30 subjects
Common carotid flow measurements may be clinically useful to determine volume responsiveness. The objective of this study was to assess the ability of emergency physicians (EP) to obtain sonographic images and measurements of the common carotid artery velocity time integral (VTi) for potential use in assessing volume responsiveness in the clinical setting. In this prospective observational study, we showed a five-minute instructional video demonstrating a technique to obtain common carotid ultrasound images and measure the common carotid VTi to emergency medicine (EM) residents. Participants were then asked to image the common carotid artery and obtain VTi measurements. Expert sonographers observed participants imaging in real time and recorded their performance on nine performance measures. An expert sonographer graded image quality. Participants were timed and answered questions regarding ease of examination and their confidence in obtaining the images. A total of 30 EM residents participated in this study and each performed the examination twice. Average time required to complete one examination was 2.9 minutes (95% CI [2.4-3.4 min]). Participants successfully completed all performance measures greater than 75% of the time, with the exception of obtaining measurements during systole, which was completed in 65% of examinations. Median resident overall confidence in accurately performing carotid VTi measurements was 3 (on a scale of 1 [not confident] to 5 [confident]). EM residents at our institution learned the technique for obtaining common carotid artery Doppler flow measurements after viewing a brief instructional video. When assessed at performing this examination, they completed several performance measures with greater than 75% success. No differences were found between novice and experienced groups.
We present a case report of a patient who initially presented with altered mental status and significant urinary frequency. Over the course of her emergency department stay, she then developed tachycardia out of proportion to a new fever along with a respiratory alkalosis. Although each objective finding has a broad differential diagnosis, thyroid storm was the only unifying diagnosis when all findings were present.
Pre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system. We retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant. 4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway. Airway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.
Flow diagram for patient inclusion
* Non-infectious ED visit (17), greater than 48 weeks postconceptional age at time of ED visit (31), and incomplete medical record (1)
** Urine with mixed flora (3), urine with <10,000 colony forming units per milliliter of a single organism (2), blood with contaminant (5), and CSF with contaminant (1)
Premature infants are at higher risk of developing serious bacterial infections (SBI). However, the incidence of SBI in ex-premature infants presenting to the emergency department (ED) remains undetermined. The objective of this study is to examine the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks presenting to a pediatric ED. A retrospective medical record review was conducted on 141 ex-premature infants with a postconceptional age of less than 48 weeks who had a full or partial septic work up completed in a pediatric ED between January 1, 1998 and March 31, 2005. The overall median gestational age at birth was 35 weeks (IQR 33-36 week) and the overall median postconceptional age at ED presentation was 40 weeks (IQR 37-42 weeks). Thirteen (9.2%) infants were found to have a SBI. Five subjects had pneumonia, four with bacteremia, two with pyelonephritis, and two with a concomitant infection of meningitis/pneumonia and bacteremia/pyelonephritis. The results of this study reveal that the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks is similar to in-term infants (9.2%) and is consistent with previously published incidence rates in-term infants (10%).
Definitions of Delayed Complications 
Demographics of all patients intubated (N = 553) 
Airway management is a critical procedure performed frequently in emergency departments (EDs). Previous studies have evaluated the complications associated with this procedure but have focused only on the immediate complications. The purpose of this study is to determine the incidence and nature of delayed complications of tracheal intubation performed in the ED at an academic center where intubations are performed by emergency physicians (EPs). All tracheal intubations performed in the ED over a one-year period were identified; 540 tracheal intubations were performed during the study period. Of these, 523 charts (96.9%) were available for review and were retrospectively examined. Using a structured datasheet, delayed complications occurring within seven days of intubation were abstracted from the medical record. Charts were scrutinized for the following complications: acute myocardial infarction (MI), stroke, airway trauma from the intubation, and new respiratory infections. An additional 30 consecutive intubations were examined for the same complications in a prospective arm over a 29-day period. The overall success rate for tracheal intubation in the entire study group was 99.3% (549/553). Three patients who could not be orally intubated underwent emergent cricothyrotomy. Thus, the airway was successfully secured in 99.8% (552/553) of the patients requiring intubation. One patient, a seven-month-old infant, had unanticipated subglottic stenosis and could not be intubated by the emergency medicine attending or the anesthesiology attending. The patient was mask ventilated and was transported to the operating room for an emergent tracheotomy. Thirty-four patients (6.2% [95% CI 4.3 - 8.5%]) developed a new respiratory infection within seven days of intubation. Only 18 patients (3.3% [95% CI 1.9 - 5.1%]) had evidence of a new respiratory infection within 48 hours, indicating possible aspiration pneumonia secondary to airway management. Three patients (0.5% [95% CI 0.1 - 1.6%]) suffered an acute MI, but none appeared to be related to the intubation. One patient was having an acute MI at the time of intubation and the other two patients had MIs more than 24 hours after the intubation. No patient suffered a stroke (0% [95% CI 0 - 0.6%]). No patients suffered any serious airway trauma such as a laryngeal or vocal cord injury. Emergency tracheal intubation in the ED is associated with an extremely high success rate and a very low rate of delayed complications. Complication rates identified in this study compare favorably to reports of emergency intubations in other hospital settings. Tracheal intubation can safely be performed by trained EPs.
Flow diagram of right upper quadrant emergency department ultrasounds
Prior studies from the emergency medicine literature addressing sensitivity and specificity of ED ultrasound.
To determine the ability of emergency department (ED) physicians to diagnose cholelithiasis with bedside ultrasound. ED gallbladder ultrasounds recorded over 37 months were compared to radiology ultrasound interpretation. Of 1,690 ED gallbladder ultrasound scans performed during this period, radiology ultrasound was performed in 575/1690 (34%) cases. ED physician bedside interpretation was 88% sensitive [95% CI, 84-91] and 87% specific [95% CI, 82-91], while positive predictive value (PPV) was 91% [88-94%] and negative predictive value (NPV) was 83% [78-87%], using radiology interpretation as the criterion reference. ED physician ultrasound of the gallbladder for cholelithiasis is both sensitive and specific.
This graph illustrates how increasing values of ST elevation (STE) + ST depression within 60 minutes of symptom onset correlates with proximal left anterior descending (LAD) occlusions. PPV, positive predictive value.
Baseline characteristics of proximal and nonproximal left anterior descending (LAD) patient groups.
ST elevation (STE) plus ST depression (II, III, aVF) data: proximal and nonproximal left anterior descending (LAD) groups.
Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) when using sum ST elevation + sum ST depression of at least 17.5 mm within 60 minutes of symptom onset to predict proximal left anterior descending occlusions in acute anterior myocardial infarctions.
Acute anterior myocardial infarctions caused by proximal left anterior descending (LAD) artery occlusions are associated with a higher morbidity and mortality. Early identification of high-risk patients via the 12-lead electrocardiogram (ECG) could assist physicians and emergency response teams in providing early and aggressive care for patients with anterior ST-elevation myocardial infarctions (STEMI). Approximately 25% of US hospitals have primary percutaneous coronary intervention (PCI) capability for the treatment of acute myocardial infarctions. Given the paucity of hospitals capable of PCI, early identification of more severe myocardial infarction may prompt emergency medical service routing of these patients to PCI-capable hospitals. We sought to determine if the 12 lead ECG is capable of predicting proximal LAD artery occlusions. In a retrospective, post-hoc analysis of the Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization pilot trial, we compared the ECG findings of proximal and nonproximal LAD occlusions for patients who had undergone an ECG within 180 minutes of symptom onset. In this study, 72 patients had anterior STEMIs, with ECGs performed within 180 minutes of symptom onset. In patients who had undergone ECGs within 60 minutes (n = 35), the mean sum of ST elevation (STE) in leads V1 through V6 plus ST depression (STD) in leads II, III, and aVF was 19.2 mm for proximal LAD occlusions and 11.7 mm for nonproximal LAD occlusions (P = 0.007). A sum STE in V1 through V6 plus STD in II, III, and aVF of at least 17.5 mm had a sensitivity of 52.3%, specificity of 92.9%, positive predictive value of 91.7%, and negative predictive value of 56.5% for proximal LAD occlusions. When the ECG was performed more than 60 minutes after symptom onset (n = 37), there was no significant difference in ST-segment deviation between the 2 groups. The sum STE (V1-V6) and STD (II, III, aVF) on a 12-lead ECG can be used to predict proximal LAD occlusions if performed within the first hour of symptom onset. This should be considered a high-risk finding and may prompt prehospital direction of such patients to PCI-capable hospitals.
Demographics of 101 patients treated in clinical decision unit for cocaine chest pain. 
Outcomes for 101 patients treated in clinical decision unit for cocaine chest pain. 
In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9-12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain. We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge. There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0-5.1%; 95% CI, 0-3.6%). Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.
Children with blunt abdominal trauma (BAT) are often hospitalized despite no intervention. We identified factors associated with emergency department (ED) disposition of children with BAT and differing computed tomography (CT) findings. We surveyed pediatric and general emergency physicians (EPs), pediatric and trauma surgeons regarding care of 2 hypothetical asymptomatic patients: a 9-year-old struck by a slow-moving car (Case 1) and an 11-month-old who fell 10 feet (Case 2). We presented various abdominal CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis, adjusting for hospital and ED characteristics, and clinician experience. Pediatric EPs served as the reference group. Of 2,003 eligible surveyed, 636 (32%) responded. For normal CTs, 99% would discharge in Case 1 and 88% in Case 2. Prominent specialty differences included: for trace intraperitoneal fluid (TIF), 68% would discharge in Case 1 and 57% in Case 2. Patients with TIF were less likely to be discharged by pediatric surgeons (Case 1: OR 0.52, 95% CI 0.32, 0.82; Case 2: OR 0.49, 95% CI 0.30, 0.79). Patients with renal contusions were less likely to be discharged by pediatric surgeons (Case 1: OR 0.55, 95% CI 0.32, 0.95) and more likely by general EPs (Case 1: OR 1.83, 95% CI 1.25, 2.69; Case 2: OR 2.37, 95% CI 1.14, 4.89). Substantial variation exists between specialties in reported hospitalization practices of asymptomatic children after abdominal trauma with minor CT findings. Better evidence is needed to guide disposition decisions.
Introduction: In emergency department (ED) patients with upper abdominal pain, management includes ruling out serious diseases and providing symptomatic relief. One of the major causes of upper abdominal pain is an ulcer caused by Helicobacter pylori (H. pylori), which can be treated and cured with antibiotics. We sought to estimate the prevalence of H. pylori infection in symptomatic patients using a convenience sample at a single urban academic ED and demonstrate the feasibility of ED-based testing. Methods: We prospectively enrolled patients with a chief complaint of pain or discomfort in the upper abdomen for 1 year from February 2011 until February 2012 at a single academic urban ED. Enrolled subjects were tested for H. pylori using a rapid point of care 13C Urea Breath Test (UBT) [Exalenz Bioscience]. We compared patient characteristics between those who tested positive versus negative for the disease. Results: A total of 205 patients with upper abdominal pain were tested over 12 months, and 24% (95% confidence interval: 19% to 30%) tested positive for H. pylori. Black subjects were more likely to test positive than white subjects (28% v. 6%, P < 0.001). Other factors, such as age and sex, were not different between the 2 groups. Conclusion: In our ED, H. pylori infection was present in 1 in 4 patients with epigastric pain, and testing with a UBT was feasible. Further study is needed to determine the risk factors associated with infection, the prevalence of H. pylori in other EDs, the effect of the test on ED length of stay and the costeffectiveness of an ED-based test-and-treat strategy.
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.
Accuracy amongst discordant pairs compared to criterion standard
Accuracy of historical features by research assistants and physicians
In many academic emergency departments (ED), physicians are asked to record clinical data for research that may be time consuming and distracting from patient care. We hypothesized that non-medical research assistants (RAs) could obtain historical information from patients with acute abdominal pain as accurately as physicians. Prospective comparative study conducted in an academic ED of 29 RAs to 32 resident physicians (RPs) to assess inter-rater reliability in obtaining historical information in abdominal pain patients. Historical features were independently recorded on standardized data forms by a RA and RP blinded to each others' answers. Discrepancies were resolved by a third person (RA) who asked the patient to state the correct answer on a third questionnaire, constituting the "criterion standard." Inter-rater reliability was assessed using kappa statistics (kappa) and percent crude agreement (CrA). Sixty-five patients were enrolled (mean age 43). Of 43 historical variables assessed, the median agreement was moderate (kappa 0.59 [Interquartile range 0.37-0.69]; CrA 85.9%) and varied across data categories: initial pain location (kappa 0.61 [0.59-0.73]; CrA 87.7%), current pain location (kappa 0.60 [0.47-0.67]; CrA 82.8%), past medical history (kappa 0.60 [0.48-0.74]; CrA 93.8%), associated symptoms (kappa 0.38 [0.37-0.74]; CrA 87.7%), and aggravating/alleviating factors (kappa 0.09 [-0.01-0.21]; CrA 61.5%). When there was disagreement between the RP and the RA, the RA more often agreed with the criterion standard (64% [55-71%]) than the RP (36% [29-45%]). Non-medical research assistants who focus on clinical research are often more accurate than physicians, who may be distracted by patient care responsibilities, at obtaining historical information from ED patients with abdominal pain.
To determine the point prevalence of urine bilirubin, urine hemoglobin and urobilinogen in blunt trauma patients, and to evaluate its utility as a screening tool for intra-abdominal injury. Data analysis of 986 consecutive trauma patients of which 698 were adult blunt trauma patients. Five-hundred sixteen subjects had a urinalysis and a CT scan of the abdomen/pelvis or exploratory laparotomy. We reviewed initial urinalysis results from trauma patients in the emergency department (ED) for the presence of urine hemoglobin, uroblinogen and urine bilirubin. Computed tomography (CT) scan results and operative reports were reviewed from the trauma registry for evidence of liver laceration, spleen laceration, bowel or mesenteric injuries. There were 73 injuries and 57/516 patients (11%) with intra-abdominal injury. Urinalysis was positive for urobilinogen in 28/516 (5.4%) patients, urine bilirubin in 15/516 (2.9%) patients and urine hemoglobin in 313/516 (61%) patients. Nineteen/forty-seven (4%) subjects had liver lacerations, 28/56 (5%) splenic lacerations, and 15/5 (3%) bowel or mesenteric injury. Comparing the proportion of patients that had urobilinogen detected in the group with and without intra-abdominal injury, 8/28 (29%) subjects with urobilinogen, 5/15 (33%) subjects with bilirubin and 47/313 (15%) subjects with urine hemoglobin were found to have liver lacerations, spleen lacerations, or bowel/mesenteric injuries. Preexisting liver or biliary conditions were not statistically associated with elevation of urine bilirubin, urine hemoglobin or urobilinogen on initial urinalysis after blunt abdominal trauma. Point prevalence for urobilinogen, urine bilirubin and urine hemoglobin are 5.43% (28/516), 2.91% (15/516) and 60.7% (313/516) respectively. The utility of the initial routine urinalysis in the ED for adult blunt abdominal trauma patients should not be used as a screening tool for the evaluation of intra-abdominal injury.
Superior mesenteric artery (SMA) syndrome is a rare cause of abdominal pain, nausea and vomiting that may be undiagnosed in patients presenting to the emergency department (ED). We report a 54-year-old male presenting to a community ED with abdominal pain and the subsequent radiographic findings.The patient's computed tomgraphy (CT) of the abdomen and pelvis demonstrates many of the hallmark findings consistent with SMA syndrome, including; compression of the duodenum between the abdominal aorta and superior mesenteric artery resulting in intestinal obstruction, dilation of the left renal vein, and gastric distension. Patients diagnosed with SMA syndrome have a characteristically short distance between the superior mesenteric artery and the aorta (usually 2-8 mm) in contrast to healthy patients (10-34 mm). Our patient's aortomesenteric distance was measured to be approximately 4 mm. Furthermore, the measured angle between the superior mesenteric artery and the aorta is reduced in patients with SMA syndrome from a normal range of 28°-65° to a measurement between 6°-22°. Our patient's aortomesenteric angle was difficult to measure secondary to poor sagittal reconstructions, but appears to be approximately 30°. Following radiographic evidence suggesting SMA syndrome together with our patient's constellation of presenting symptoms, a diagnosis of SMA syndrome was made and the patient was admitted to the general surgery service. However, our patient decided to leave against medical advice owing to improvement of his symptoms following the emptying of two liters of gastric contents via nasogastric tube evacuation.
Clinical Findings in Thyrotoxicosis. 
This case report describes an unusual presentation of an emergency department (ED) patient with nausea, vomiting, and epigastric pain, who was initially suspected of having viral hepatitis. The patient returned to the ED seven days later with persistent tachycardia and was diagnosed with new onset thyrotoxicosis.
We present a case of acute appendicitis from mobile cecum presenting with left upper quadrant abdominal pain.
Overall general patient characteristics 
Age differences in patient characteristics 
Logistic regression of characteristics associated with analgesic treatment with clustering on physician 
To determine the association between age and analgesia for emergency department (ED) patients with abdominal or back pain. Using a fully electronic medical record, we performed a retrospective cohort study of adults presenting with abdominal or back pain to two urban EDs. To assess differences in analgesia administration and time to analgesia between age groups, we used chi-square and Kruskal-Wallis test respectively. To adjust for potential confounders, we used a generalized linear model with log link and Gaussian error. Of 24,752 subjects (mean age 42 years, 65% female, 69% black, mean triage pain score 7.5), the majority (76%) had abdominal pain and 61% received analgesia. The ≥80 years group (n=722; 3%), compared to the 65-79 years group (n=2,080; 8%) and to the <65 years group (n=21,950; 89%), was more often female (71 vs. 61 vs. 65%), black (72 vs. 65 vs. 69%), and had a lower mean pain score (6.6 vs. 7.1 vs. 7.6). Both older groups were less likely to receive any analgesia (48 vs. 59 vs. 62%, p<0.0001) and the oldest group less likely to receive opiates (35 vs. 47 vs. 44%, p<0.0001). Of those who received analgesia, both older groups waited longer for their medication (123 vs. 113 vs. 94 minutes; p<0.0001). After controlling for potential confounders, patients ≥80 years were 17% less likely than the <65 years group to receive analgesia (95% CI 14-20%). Older adults who present to the ED for abdominal or back pain are less likely to receive analgesia and wait significantly longer for pain medication compared to younger adults.
Repeat computed tomography scan showed marked dilatation (arrow) of the cecum up to 10.5 cm with a transition point in the right lower quadrant suspicious for obstruction and cecal volvulus. 
Repeat visits to an emergency department (ED) within a short period of time for recurring or continuing abdominal pain should make physicians suspicious for relapsing or episodic disease processes. I present a case of a 17-year-old female with cecal volvulus found only after multiple ED visits.
We present a case of pylephlebitis, which is an infective suppurative thrombosis of the portal vein. Pylephlebitis is an uncommon complication of intra-abdominal infections and carries with it significant morbidity and mortality.
A 4-year-old girl was brought to our hospital by her parents because of abdominal pain. She had suffered minor trauma after rolling from her standard-height bed 2 days prior. Vital signs were appropriate for age. Physical examination was remarkable for decreased breath sounds to the left side of the chest. A chest radiograph (Figure) demonstrated a large gas-filled structure in the left side of the chest with mediastinal shift.
Top-cited authors
Michael P Wilson
Scott L Zeller
  • University of California, Riverside
Shahram Lotfipour
  • University of California, Irvine
Martin Huecker
  • University of Louisville
Avrim Fishkind
  • JSA Health