Adam H. Miller

Acutely Decompensated Heart Failure in a County Emergency Department: A Double-Blind Randomized Controlled Comparison of Nesiritide Versus Placebo Treatment

STUDY OBJECTIVE Acutely decompensated congestive heart failure is a major cause of emergency department (ED) visits in county hospitals. This often underserved population has a high rate of return visits to the ED for heart failure. Nesiritide has been demonstrated to relieve symptoms of acutely decompensated congestive heart failure. We examined the effect of an 8-hour infusion of nesiritide on the composite of return to the ED or hospitalization at 30 days. METHODS A prospective, randomized, double-blinded, placebo-controlled trial of nesiritide plus protocol-specified standard therapy versus standard therapy done in the ED for acutely decompensated congestive heart failure. RESULTS One hundred one patients were randomized during a 16-month enrollment period. Sixty-six percent of the patients were men and 34% were women. Fifty-six percent were black; all patients had New York Heart Association class II to IV heart failure and most had dyspnea at rest or with minimal exertion. Complete follow-up data were available in 97 of 101 patients. After the 8-hour treatment period, acute symptom relief was experienced in 95.7% of the nesiritide group (95% confidence interval [CI] 88.9% to 100%) versus 86.8% of the placebo group (95% CI 72% to 98.9%), with an absolute difference between the 2 groups of 8.9% (95% CI -3.3% to 24.2%). Diuresis was similar between the 2 groups, but hypotension occurred more frequently in the nesiritide-treated group. The primary outcome measure of return visit to the ED or hospitalization at 30 days was higher for nesiritide (41.5%) than placebo (39.6%; absolute difference 1.9%; 95% CI -17.2% to 21.1%). There was only 1 death. No measurable change in renal function was observed. CONCLUSION Administration of nesiritide for acutely decompensated congestive heart failure in a county ED was no better than standard therapy alone for return to the ED or hospitalization at 30 days.

Mechanical devices for cardiopulmonary resuscitation

Purpose of the reviewFor over 40 years, manual chest compressions have been the foundation of cardiopulmonary resuscitation and recent studies have clearly reconfirmed the hemodynamic significance of delivering consistent, high-quality, infrequently-interrupted chest compressions. However, there remain multiple inadequacies in the actual delivery of manual chest compressions during cardiopulmonary resuscitation. One potential solution is use of adjunct mechanical devices. Recent findingsTwo different methods of accessory chest compression techniques recently have demonstrated enhanced short-term survival. The active compression-decompression device is a hand-held, manually operated suction device applied to the center of the chest wall. In tandem with an impedance threshold (airway) device, active compression-decompression has shown a 65% improvement in 24-hour survival rates (compared with standard cardiopulmonary resuscitation) in a randomized out-of-hospital clinical trial (n = 210). The second device, called Auto-Pulse CPR is an automated machine that uses a load-distributing, broad compression band that is applied across the entire anterior chest. A recent out-of-hospital retrospective case-control study (n = 162) also revealed improved short-term survival. SummaryHigh quality chest compressions during cardiopulmonary resuscitation are critical elements in effecting successful resuscitation following a cardiac arrest. Recent studies utilizing adjunct mechanical devices have not only revealed significant increases in the effectiveness of chest compressions, including improved hemodynamics in both animal models and human studies, but also improvements in short-term human survival in the clinical setting. It is hoped that these promising findings will eventually be corroborated in terms of improved neurologically intact, long-term patient survival. Clinical trials are currently underway to validate such efficacy.

Is Coronary Computed Tomography Angiography a Resource Sparing Strategy in the Risk Stratification and Evaluation of Acute Chest Pain? Results of a Randomized Controlled Trial

OBJECTIVES Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD. METHODS Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs. RESULTS The mean (± standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group (

Incomplete Kawasaki disease.

10,134; SD ±

Ischemic stroke presenting as fluctuating focal weakness in an otherwise healthy young man

14,239) versus the SC-only group (

Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department

16,579; SD ±

Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study

19,148; p = 0.144), as was the median for the SC + CCTA (

ED ultrasound in hepatobiliary disease

4,288) versus SC only (

Diplopia: A focal neurologic presentation of West Nile meningoencephalitis

12,148; p = 0.652; median difference = -

Lunesta overdose: ST-elevation coronary vasospasm, troponemia, and ventricular fibrillation arrest

1,291; 95% confidence interval [CI] = -