Prospective Study of the Clinical Features and Outcomes of Emergency Department Patients with Delayed Diagnosis of Pulmonary Embolism

Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED.
Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock).
Results: Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [±15] vs. 51 [±17] years; p < 0.001), had a longer median time to heparin administration (33 vs. 8 hours; p < 0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01).
Conclusions: In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED.     

Dehydration and Orthostatic Vital Signs in Women with Hyperemesis Gravidarum

Objectives: To assess the hydration status of women presenting to an ED with hyperemesis gravidarum and to determine whether clinically relevant changes in orthostatic vital signs occur.
Methods: A convenience sample of 23 pregnant women who had hyperemesis gravidarum, with each patient serving as her own control. The study took place in the ED observation unit of an urban teaching hospital. Women who had pregnancies of ≤16 weeks' gestation who had been vomiting for at least 24 hours were included. Supine and standing pulse rates and blood pressures (BPs) were measured sequentially after 5 minutes in each position. Patient weight and urine specific gravity (SG) also were recorded. After 6 L of lactated Ringer's solution was infused over a 12-hour period, the same measurements were repeated. Pre- and posthydration changes were analyzed using the paired t-test.
Results: The mean treatment weight gain as a percentage of the total body weight was 5.6% ± 2.2% (mean ± SD). The urine SG decreased from 1.027 ± 0.004 to 1.008 ± 0.003 (p < 0.001). The mean change in systolic BP upon assuming the standing position was -8.3 ± 12.7 mm Hg before hydration vs 2.9 ± 7.8 mm Hg after hydration (p < 0.001). The corresponding change in mean diastolic BP was 3.7 ± 10.9 mm Hg before hydration vs 8.6 ± 10.9 mm Hg after hydration (p = 0.12). The mean change in pulse rate upon standing was 26.8 ± 14.5 beats/min before hydration vs 14.5 ± 10.1 beats/min after hydration (p = 0.002).
Conclusions: Women who present to the ED with hyperemesis gravidarum are significantly dehydrated and experience measurable improvement in postural pulse rate and systolic BP changes with rehydration. However, the presenting orthostatic changes lack sufficient sensitivity to be effectively used as quantitative screening tests for dehydration.     

The Significance of Out-of-hospital Hypotension in Blunt Trauma Patients

Objective: To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.
Methods: A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP ≤90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture.
Results: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).
Conclusion: The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.     

Early Experience with Robotic Navigation for Catheter Ablation of Paroxysmal Atrial Fibrillation

Introduction: Pulmonary venous antra isolation (PVAI) is the cornerstone of catheter ablation procedure for drug refractory paroxysmal atrial fibrillation (AF). However, the procedure is technically challenging. Robotic navigation has a potential to expedite and facilitate the procedure.
Methods: A robotic catheter control system was used for remote navigation-supported PVAI in 22 patients (mean age = 55 ± 9 years, 16 males, study group). An irrigated-tip catheter with estimate of catheter force on the tissue was used. This was compared in nonrandomized fashion with conventional hand-controlled catheter ablation in 16 patients (mean age = 55 ± 9 years, 13 males, control group). The procedures were performed under guidance of Ensite NavX navigation system (St. Jude Medical, St. Paul, MN, USA) and intracardiac echocardiography.
Results: Robotic navigation was associated with significantly shorter overall duration of radiofrequency delivery (1,641 ± 609 vs 2,188 ± 865 seconds, P < 0.01), shorter total procedural time (207 ± 29 vs 250 ± 62 minutes, P = 0.007), fluoroscopy exposure (15 ± 5 vs 27 ± 9 minutes, P < 0.001), and lower radiation dose (1,119 ± 596 vs 3,048 ± 2,029 mGy/m², P < 0.001). No complication was observed in either the study or the control group. During the 5 ± 1 months follow-up in the study group and 9 ± 3 months in the control group, 91% and 81% of patients, respectively, were AF free.
Conclusions: In our early clinical experience, PVAI using a remote robotic catheter navigation was effective, safe, and associated with shorter procedural and fluoroscopic times than conventional PVAI.     

Comparison of Hydromorphone and Meperidine for Ureteral Colic

Objective: To compare the efficacies of meperidine and hydromorphone in the treatment for ureteral colic in the emergency department (ED).
Methods: A prospective, double-blind, randomized clinical trial was conducted over six months at a tertiary referral center with 93,000 annual ED visits. Seventy-three patients completed the study. The patients received either 1 mg of hydromorphone or 50 mg of meperidine IV at t = 0. Pain intensity was determined using a 10-cm visual analog scale at t = 0, 15, 30, 60, and 120 minutes. A second dose of the study drug could be given between t = 15 and t = 120 minutes when the clinician believed the initial dose was ineffective. Patients requiring more than one additional dose of analgesia were treated as nonresponders and were removed from the study.
Results: Thirty-six patients received hydromorphone and 37 received meperidine. The initial pain intensities (hydromorphone group = 8.4 ± 1.5; meperidine group = 8.5 ± 2.1), age distributions, sex distributions, and side effects of the two groups were comparable. Pain relief was better (p < 0.05) with hydromorphone at t = 15, 30, 60, and 120 minutes. The hydromorphone group required rescue analgesia less often (31% vs 68%, p < 0.01), had fewer IV pyelographies (IVPs) (28% vs 54%, p < 0.05), and had a lower proportion of hospital admissions (25% vs 49%, p = 0.08).
Conclusions: For the fixed doses used in this study, the adult ureteral colic patients receiving hydromorphone achieved more pain relief, required less rescue medication, underwent fewer IVPs, and avoided hospital admission more frequently than did those receiving meperidine.     

Do Admitted Patients Held in the Emergency Department Impact the Throughput of Treat-and-release Patients?

Objective: To examine the impact of reducing ED "boarders" (through the use of a short-stay inpatient medicine unit) on the amount of time that treat-and-release patients spend in the ED.
Methods: A retrospective analysis of hours spent in the ED was made at a university hospital teaching ED for treat-and-release patients in 4 clinical categories: chest pain, asthma exacerbation, sickle-cell crisis, and seizure. The average hours per patient spent in the ED during the 4-month intervals before (August-November 1993) and after (August-November 1994) the establishment of the short-stay medicine unit were compared. Data were analyzed using the 2-tailed, unpaired t-test.
Results: This short-stay inpatient medicine unit received on average 135 patients per month from the ED, with an average length of stay of 2.4 days. The mean (±SD) number of admitted patients per day waiting in the ED >8 hours for an inpatient bed dropped from 9.6 ± 4.2, before the institution of this unit, to 2.3 ± 2.6. There was a significant reduction in the average number of hours spent in the ED by treat-and-release patients with chest pain (from 7.3 ± 6.0 to 5.5 ± 4.8 hr/patient, p c 0.001) and asthma exacerbation (from 5.0 ± 3.6 to 4.2 ± 2.9 hdpatient, p < 0.05), but not with sickle-cell crisis or seizure, after the implementation of the short-stay unit.
Conclusion: Reducing the number of admitted patients waiting in the ED for inpatient beds, in this case by establishment of a short-stay medicine unit, is associated with a decrease in the interval that treat-and-release patients spend in the ED.     

T HE E FFECTS OF P REHOSPITAL A DVANCED L IFE S UPPORT D RUG T REATMENT ON P ATIENT I MPROVEMENT AND I N-HOSPITAL U TILIZATION

Objective. There is little published evidence to support the benefits of prehospital drug administration by ambulance personnel in reducing subsequent hospital utilization by the medical patients receiving such drugs. The authors studied the outcome of patients treated by Ontario's Emergency Health Services “Symptom Relief Drug Program,” which was developed to relieve patient symptoms in the field for specific medical emergencies. Methods. A retrospective study spanning a three-year period from January 1996 to December 1998 was undertaken in a mid-sized southern Ontario community. From a review of ambulance call reports (ACRs), eligible patients were recruited by mail and divided into two groups: those treated before the introduction of the program (pre) and those treated after (post). Out-of-hospital data were retrieved from ACRs and in-hospital data were gathered from medical chart reviews. Outcomes included emergency department (ED) length of stay (LOS), frequency of admissions, and departmental use. Secondary endpoints included differences in prehospital improvement, ED interventions, and ambulance scene times. Results. For the unpaired analysis, 406 patients provided consent (pre: 215 vs post: 191). Ambulance time on scene was longer in the post group, 14.2 minutes (95% CI 13.7–14.8), versus the pre group, 12.3 minutes (95% CI 11.7–12.9), p < 0.001. A larger proportion of patients receiving prehospital drug treatment were judged to have improved on ED arrival (pre: 19.5% vs post: 48.2%, χ² p < 0.0001). The ED LOSs did not differ between groups (pre: 206.9?min, 95% CI 185.9–230.4, vs post: 220.9?min, 95% CI 196.9–247.7, p = 0.42) but were shorter within the post group for hypoglycemic patients receiving glucagon. The overall proportion of admissions was significantly lower in the post group (pre: 145 [67.4%] vs post: 102 [54.3%], χ² p < 0.01), and this was driven by chest pain patients. Conclusions. The lower rate of admissions for chest pain patients is the first published evidence of prehospital drug treatment's reducing hospital utilization in a subgroup of such medical patients. The “Symptom Relief Drug Program” is effective in improving patients' field conditions and can decrease ED LOS in hypoglycemic persons receiving glucagon injections. More outcome research pertaining to ambulance-administered prehospital drug treatment is warranted.     

Brief Motivational Intervention to Increase Self-reported Safety Belt Use among Emergency Department Patients

Objectives:  Brief motivational interventions have shown promise in reducing harmful behaviors. The authors tested an intervention to increase safety belt use (SBU) among emergency department (ED) patients.
Methods:  From February 2006 to May 2006, the authors conducted a randomized trial of adult ED patients at a teaching hospital in Boston. ED patients were systematically sampled for self-reported SBU. Those with SBU other than "always" were asked to participate. At baseline, participants answered a 9-item series of situational SBU questions, each scored on a 5-point Likert scale. SBU was defined as a continuous variable (9-item average) and as a dichotomous variable (response of "always" across all items). Participants were randomized to an intervention or a control group. The intervention group received a 5- to 7-minute intervention, adapted from classic motivational interviewing techniques, by a trained interventionist. Participants completed a 3-month follow-up phone survey to determine changes from baseline SBU. Continuous and dichotomous SBU were analyzed via analysis of covariance and chi-square testing.
Results:  Of 432 eligible patients, 292 enrolled (mean age 35 years, standard deviation [SD] ±11 years; 61% male). At baseline, the intervention and control groups had similar mean (±SD) SBU scores (2.8 [±1.1] vs. 2.6 [±1.1], p = 0.31) and SBU prevalence (each 0%). At 3 months, 81% completed follow-up. The intervention group had significantly greater improvement in mean (±SD) SBU scores than controls (0.76 [±0.91] vs. 0.34 [±0.88], p < 0.001). Also, SBU prevalence of "always" was higher for the intervention group than controls (14.4% vs. 5.9%, p = 0.03).
Conclusions:  Participants receiving a brief motivational intervention reported higher SBU at follow-up compared to controls. An ED-based intervention may be useful to increase SBU.     

Effect of Continuous Quality Improvement Methods on Reducing Triage to Thrombolytic Interval for Acute Myocardial Infarction

Objectives: To assess the timeliness of thrombolytic therapy in the ED for selected patients with acute myocardial infarction (AMI) following continuous quality improvement (CQI) interventions.
Methods: A retrospective, historical comparison study was performed of triage-to-thrombolytic time intervals for AMI patients using chart review for data collection. Patients treated after implementation of the CQI process vs a historical control group were compared. The patients with AMI who had received thrombolytics during the one-year period prior to the CQI interventions and who had documentation of time intervals served as the control group. The patients treated during a four-month period, beginning about one and a half years following introduction of the CQI interventions, served as the intervention group. Interventions included: a triage protocol, CQI review, and staff feedback.
Results: The mean triage-to-thrombolytic interval was longer for the control group (72 ± 25 vs 40.0 ± 22 min; p < 0.0001). The mean triage-to-ECG interval also was longer for the control group (16.5 ± 8.9 vs 8.5 ± 7.5 min; p < 0.0001). Most (79%) of the study group received thrombolytic therapy within 60 minutes, and 39% within 30 minutes, whereas 39% of the control group received thrombolytic therapy within 60 minutes, and 3% within 30 minutes.
Conclusion: The implementation of CQI techniques, including 100% chart review, intensive systems analysis, and staff feedback, had a positive effect on the timeliness of thrombolytic therapy for the ED patients who had AMI. As a result, most (79%) of the patients received therapy within the 60-minute time window recommended currently by the American Heart Association.     

The Complete Blood Count and Reticulocyte Count–Are They Necessary in the Evaluation of Acute Vasoocclusive Sickle-cell Crisis?

Objective : To assess the usefulness of the complete blood count (CBC) and the reticulocyte count in the evaluation of adult patients with acute vasoocclusive sickle-cell crisis (SCC) presenting to the ED.
Methods : A 2-part study was performed. Part 1 was a retrospective chart review of patients with a sole ED diagnosis of acute SCC. Part 2 was a prospective evaluation of consecutive patients presenting in SCC. In both parts of the study, patients with coexisting acute disease were excluded. The remaining patients were divided into 2 groups: admitted and released. The mean values for white blood cell (WBC) count, hemoglobin (Hb) level, and reticulocyte count were compared. In Part 2. the change (Δ) from the patient's baseline in WBC count, Hb level, and reticulocyte count also was determined. Data were analyzed by 2-tailed Student's t-test.
Results : Part 1: There was no difference between the admitted ( n = 33) and the released ( n = 86) groups in mean WBC count (p = 0.10), Hb level (p = 0.25), or reticulocyte count (p = 0.08). Part 2: There was no difference between the admitted ( n = 44) and the released ( n = 160) groups in mean Hb level (p = 0.88). reticulocyte count (p = 0.47). AHb level (p = 0.88). and Areticulocyte count (p = 0.76). There was a difference in mean WBC counts (15.8 ± 4.9 × 10⁹/L admitted vs 12.8 ± 4.9 × 10⁹/L released, p = 0.003) and ΔWBC counts (5.1 ± 4.6 × 10⁹/L admitted vs 1.8 ± 4.6 × 10⁹/L released, p < 0.002).
Conclusion : Determination of the Hb level and the reticulocyte count do not appear useful in the evaluation of acute SCC in the ED. Admission decisions appear associated with elevations in the WBC count. Further study is required to determine the true value of the WBC count in such decisions.     

Endocardial Electrogram Analysis after Intramyocardial Injection of Mesenchymal Stem Cells in the Chronic Ischemic Myocardium

Background: Cell injection therapies have been introduced for the treatment of patients with coronary heart disease. However, intramyocardial injection of bone marrow (BM)-derived cells may generate proarrhythmogenicity.
Methods: Two weeks after the placement of a circumflex artery-ameroid constrictor, 21 pigs received mesenchymal stem cells (MSC, n = 9), mononuclear (BM)-derived stem cells (MNC, n = 6), and placebo (n = 6) using a electromechanical mapping (EMM)-guided percutaneous transendocardial injection catheter. At week 6, EMM was repeated and the injected areas were analyzed in detail to evaluate local bipolar electrogram fragmentation, duration, and amplitude. Myocardial fibrosis was evaluated by a quantitative histological analysis.
Results: At week 6, the injection of MSC or MNC did not increase local electrogram fragmentation (MSC group: 1.4 ± 0.3 vs. 1.3 ± 0.2; MNC group: 1.4 ± 0.2 vs. 1.3 ± 0.2; P = NS), prolong electrogram duration (MSC group: 27.1 ± 7.8 ms vs. 23.7 ± 2.0 ms; MNC group: 27.8 ± 3.5 ms vs. 26.8 ± 5.6 ms; P = NS), or decrease bipolar voltages (MSC group 2.7 ± 0.9 mV vs. 2.8 ± 1.0 mV; MNC group 2.0 ± 1.0 mV vs. 1.7 ± 0.4 mV). From week 2 to week 6, mean left ventricular ejection fraction increased in the MSC group (37.9 ± 4.2% vs. 45.9 ± 2.2%; P = 0.039) only. Histological analysis of the ischemic regions revealed 17.6 ± 5% myocardial fibrosis in the MNC group vs. 13.6 ± 3.4% MSC vs. 28.7 ± 8.7% in the control group (P = 0.038 and P = 0.013). No death occurred in any animal after the injection procedure.
Conclusion: Intramyocardial injection of MSC or MNC do not increase fragmentation and duration of endocardial electrograms in the injected ischemic myocardium but attenuate ischemic damage and therefore may not create an electrophysiological substrate for reentry tachycardias     

Simple standing test predicts and water ingestion prevents vasovagal reaction in the high-risk blood donors

BACKGROUND: One of the serious complications of blood donation is vasovagal reaction (VVR) with syncope. This study was performed to determine if the measurement of hemodynamic responses to standing before blood collection (BC) was useful to identify the high-risk donors for VVR and also examined the effect of 300 mL of water ingestion in the prevention of VVR.
STUDY DESIGN AND METHODS: Blood pressure and heart rate (HR) during 5 minutes of standing were examined before and after BC in 93 donors. Because HR increase of 6 of 7 donors who developed syncopal VVR during standing after BC was 15 beats per minute (bpm) or greater, those with HR increase of 15 bpm or greater were determined as high-risk donors (n = 31). In another group (n = 117), 45 donors were identified as high risk based on the HR response before BC (≥15 bpm). The effect of 300 mL of water ingestion 15 minutes before BC on hemodynamic responses to standing and the rate of VVR after BC were analyzed.
RESULTS: Water ingestion given to the high-risk donors of the second group reduced HR increase with standing before BC (−6.6 ± 13.6 bpm, p < 0.02 vs. HR increase before water ingestion) and significantly suppressed VVR rate (2 of 45 donors with high risk, 4.4%, p < 0.04 vs. the first group; 6 of 31 high-risk donors, 19.4%).
CONCLUSION: HR response to standing before BC may detect the high-risk donors for VVR. For the high-risk donors, 300 mL of water ingestion may be a simple and effective way of prevention against syncopal VVR.     

University and Community Hospital Medical Student Emergency Medicine Clerkship Experiences

Objective : To determine whether there is a significant difference between educational opportunities for fourth-year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship.
Methods : A self-reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six-hour shifts. They rated the EM attending clinical teaching by site using a 5-point scale at the end of the clerkship.
Results : Most (95%) of the 87 students in the 7 clerkship blocks of the 1996–97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 ± 0.10 vs 2.8 ± 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 ± 0.04 vs 0.56 ± 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs.
Conclusions : The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.     

Emergency Department Utilization by the Elderly: Analysis of the National Hospital Ambulatory Medical Care Survey

Objective : To characterize the ED utilization patterns of the elderly population using nationally representative data.
Methods : A secondary analysis was performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide, stratified probability sample of ED encounters. Using these physician-reported data, the demographics, patient complaints, physician diagnoses, and dispositions were compared by age group, i.e., young-old (age 65–84 years) vs old-old (age ±85 years).
Results : The elderly (age ±65 years) represented 5,038 (19.6%) of 25,646 ED encounters for all adults (age ±18 years). The geriatric age groups (ages 65–74, 75–84, and ±85 years) accounted for 45.3%, 37.4%, and 17.2% of all the encounters by the elderly. The proportions of female patients and white patients were higher with increasing age. The proportion of elderly patients hospitalized was 4 times that of younger adults and reflected monotonic increase with increasing age among elders. Patient complaints and physician diagnoses were generally similar for the young-old (65–84 years) and the old-old (±85 years).
Conclusions : These findings are consistent with previous single-center studies of geriatric ED patients. This data source may be useful for investigation of clinical issues related to the care of elderly ED patients.     

Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain

Objective: To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain.
Methods: Prospective, double-blind, placebo-controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60, 000 visits. Patients ±18 years old who had abdominal pain for ± 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved.
Results: Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED: 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 2 2.8 cm, than it did for the NS group, 0.8 ± 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 ± 0.5 mL vs 1.8 ± 0.4 mL (p <0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group.
Conclusions: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients. Key words: abdominal pain; analgesia; analgesics; emergency department; morphine; opiates; pain.     

The Effects of Combined Intravenous and Inhaled Steroids (Beclomethasone Dipropionate) for the Emergency Treatment of Acute Asthma

Objective : To compare the efficacy of high-dose inhaled steroids in conjunction with IV steroids with that of IV steroids alone in the emergency treatment for acute asthma.
Methods : A double-blind, placebo-controlled, randomized trial was conducted on 60 ED patients presenting with acute asthma. All patients received nebulized salbutamol, and IV methylprednisolone, 80 mg at baseline and 40 mg at 6 hours. In addition to the above therapy, the experimental group received beclomethasone dipropionate (BDP) 7 mg over 8 hours via a metered-dose inhaler (MDI) attached to a holding chamber, while the control group received a placebo administered in the same fashion. Patients were treated on the protocol for 12 hours with the primary outcome measure being the change in % predicted FEV₁.
Results : Of 60 patients, 30 were randomized to BDP (age: 42 ± 16 years; FEV₁: 0.97 ± 0.42 L) and 30 were randomized to placebo (age: 37 ± 18 years; FEV₁: 0.98 ± 0.35 L). Spirometry and dyspnea measured by the Borg Scale improved significantly in both groups compared with baseline (p < 0.001). Changes in spirometry measures, dyspnea, and vital signs did not differ between treatment groups over the 12 hours of study (p > 0.05).
Conclusion : Inhaled BDP added to the standard regimen of IV methylprednisolone, and β-agonist did not further improve flow rates or dyspnea scores measured for up to 12 hours after presentation to the ED.     

Association of Out-of-hospital Criteria with Need for Hospital Admission

Objective: To validate high-risk historical and physiologic out-of-hospital criteria as predictors of the need for hospitalization following ED evaluation.
Methods: Consecutive patients entered into the Suffolk County advanced life support system were enrolled. Previously proposed historical and physiologic "high-risk" criteria for hospitalization were prospectively collected. Criteria were associated with the need for hospital admission following ED evaluation.
Results: 1,238 patients were enrolled; 391 were released from an ED after transport. Most patients (843/1,238; 68%) were admitted to a hospital; and four died in the ED. Factors associated with an increased likelihood of admission or death among the transported patients were: bradycardia (90% admitted, p < 0.02); hypotension (80%, p < 0.03); hypertension (89%, p < 0.03); and age > 55 years (81%, p < 0.0001). Unresponsiveness and other abnormal vital signs were not associated with admission on univariate analysis. Logistic regression analysis identified two other factors associated with admission or death: tachycardia (72%, admitted, p < 0.01) and head injury (78% admitted. p < 0.001).
Conclusions: Abnormal pulse or blood pressure, head injury, and age > 55 years are associated with patients' requiring hospital admission after accessing the emergency medical services system. These criteria may aid the design of out-of-hospital refusal-of-care policies.     

Prognostic Value of Symptoms during a Normal or Nonspecific Electrocardiogram in Emergency Department Patients with Potential Acute Coronary Syndrome

Objectives Emergency department (ED) patients with symptoms concerning for acute coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for adverse cardiovascular events. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do those who are asymptomatic.
Methods This was a prospective cohort study of ED patients with potential ACS. Outcomes were acute myocardial infarction (AMI), ACS, and 30-day cardiovascular events (death, AMI, revascularization). Fisher's exact test, t-tests, and logistic regression were used for data analysis.
Results Of 2,593 patient visits, 2,007 patients had normal or nonspecific ECG findings. There were 1,196 who had symptoms during ECG, whereas 811 did not. Patients with symptoms at ECG acquisition were younger (49.9 vs. 55.2 years; p < 0.001) and were more likely to be black (70% vs. 64%; p = 0.002), female (63% vs. 58%; p = 0.03), and to have used cocaine (5% vs. 2%; p = 0.004). They were less likely to have hypertension (49% vs. 58%; p < 0.001), and diabetes (22% vs. 17%; p = 0.002). Patients with and without symptoms were equally likely to have AMI (both 2.8%; p > 0.99), ACS (10.1% vs. 11.5%; p = 0.34), and 30-day adverse outcomes (both 5.3%; p > 0.99). After adjustment for baseline cardiovascular-risk factors, odds ratios for patients with symptoms at the time of ECG acquisition were not significantly different for any of the outcomes: AMI (1.1; 95% confidence interval [CI] = 0.6 to 1.9); ACS (1.1; 95% CI = 0.8 to 1.4); or 30-day events (1.2; 95% CI = 0.8 to 1.9).
Conclusions Patients who are symptomatic during acquisition of a normal or nonspecific ECG have rates of adverse cardiovascular events similar to those of patients without symptoms. Clinicians should not rely on the absence of ECG abnormalities during symptoms to help exclude ACS.     

Brugada-Like Changes in the Peripheral Leads during Diagnostic Ajmaline Test in Patients with Suspected Brugada Syndrome

Background: Although cases of Brugada-type electrocardiographic (ECG) pattern in peripheral (limb) leads have been reported ("atypical" Brugada syndrome [BS]), their incidence in patients investigated for BS is unknown.
Methods: We retrospectively analyzed an ECG database collected during ajmaline test in 143 patients (89 men) with suspected BS. In 42 patients, 12-lead ECGs were recorded, whereas in 101 patients, leads V1–V3 from the third intercostal space were also recorded. The presence of types 1, 2, and 3 Brugada pattern in each limb and precordial lead was noted and the PR, QRS, and QTc intervals were calculated.
Results: There were 114 (79.7%) negative and 29 (20.3%) positive tests. Type 1 pattern developed in ≥1 limb lead in six patients (4.2%) (3/29 with positive tests, 10.3%); all of them were male, symptomatic, and/or with family history of BS or sudden cardiac death. Their pre- and posttest QRS were significantly longer compared with the rest with positive (n = 26) or negative (n = 111) test (pretest: 129 ± 31 ms vs 101 ± 11 ms and 97 ± 12 ms, P < 0.001; posttest: 175 ± 44 ms vs 134 ± 14 ms and 131 ± 19 ms, P < 0.001). The posttest QTc was longer in patients with peripheral changes compared with the rest (507 ± 47 ms vs 453 ± 22 ms and 447 ± 24 ms, P < 0.001). The pretest QTc and pre- and posttest heart rate and PR intervals were not significantly different between the three groups.
Conclusions: Type 1 Brugada pattern in the peripheral leads was observed in 4.2% of patients during ajmaline test (10.3% of positive tests) and was associated with longer QRS and greater QTc prolongation compared with the rest of the patients.