Charles L. Emerman

Impact of intravenous loop diuretics on outcomes of patients hospitalized with acute decompensated heart failure: insights from the ADHERE registry.

The optimal use of diuretics in decompensated heart failure remains uncertain. We analyzed data from the ADHERE registry to look at the impact of diuretic dosing. 62,866 patients receiving <160 mg and 19,674 patients ≥160 mg of furosemide were analyzed. The patients receiving the lower doses had a lower risk for in-hospital mortality, ICU stay, prolonged hospitalization, or adverse renal effects. These findings suggest that future studies should evaluate strategies for minimizing exposure to high doses of diuretics.

Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis

Objective: Morphine is a long-standing therapy in acute decompensated heart failure (ADHF), despite few supporting data. A study was undertaken to compare the outcomes of patients who did and did not receive morphine for ADHF. Methods: The study was a retrospective analysis of the Acute Decompensated Heart Failure National Registry (ADHERE) which enrols hospitalised patients with treatment for, or a primary discharge diagnosis of, ADHF. Patients were stratified into cohorts based on whether or not they received intravenous morphine. ANOVA, Wilcoxon and χ2 tests were used in univariate analysis, followed by multivariate analysis controlling for parameters previously associated with mortality. Analyses were repeated for ejection fraction subgroups and in patients not on mechanical ventilation. Results: There were 147 362 hospitalisations in ADHERE at December 2004, 20 782 of whom (14.1%) received morphine and 126 580 (85.9%) did not. There were no clinically relevant differences between the groups in the initial age, heart rate, blood pressure, blood urea nitrogen, creatinine, haemoglobin, ejection fraction or atrial fibrillation. A higher prevalence of rest dyspnoea, congestion on chest radiography, rales and raised troponin occurred in the morphine group. Patients on morphine received more inotropes and vasodilators, were more likely to require mechanical ventilation (15.4% vs 2.8%), had a longer median hospitalisation (5.6 vs 4.2 days), more ICU admissions (38.7% vs 14.4%), and had greater mortality (13.0% vs 2.4%) (all p<0.001). Even after risk adjustment and exclusion of ventilated patients, morphine was an independent predictor of mortality (OR 4.84 (95% CI 4.52 to 5.18), p<0.001). Conclusions: Morphine is associated with increased adverse events in ADHF which includes a greater frequency of mechanical ventilation, prolonged hospitalisation, more ICU admissions and higher mortality.

A comparison of EMT judgment and prehospital trauma triage instruments.

A number of instruments have been devised to aid in the triage of trauma patients. Little work, however, has been done to demonstrate that these triage instruments offer an advantage over the judgment of an emergency medical technician (EMT) in determining which patients require transportation to a trauma center. The purpose of this study was to compare EMT judgment against three scoring systems; the triage-revised Trauma Score, the Prehospital Index, and the CRAMS scale. Data were gathered on trauma victims transported by the City of Cleveland EMS system. The EMTs rated the patients overall severity on a 4-point scale and estimated the probability of patient mortality. We found that the EMT prediction of mortality was as accurate as the various scores. In a subset of patients, we also found that the EMT assessment performed as well as the scoring systems in identifying patients who either died or required emergent operative intervention. We conclude that EMT judgment is as accurate as these three scoring systems in identifying patients at high risk for death or the need for immediate operative intervention.

Impact of Early Initiation of Intravenous Therapy for Acute Decompensated Heart Failure on Outcomes in ADHERE

Background: Since most acute decompensated heart failure (ADHF) patients present for hospital care via the emergency department (ED), we sought to determine the impact of early ED initiation of ADHF-specific therapy, as indicated by nesiritide use, on subsequent outcomes. Methods: We queried the Acute Decompensated Heart Failure National Registry (ADHERE®) to identify patients with initial systolic blood pressure >90 mm Hg and negative cardiac biomarkers, hospitalized after presentation to the ED, who received nesiritide but no other intravenous vasoactive drugs. Intensive care unit use and total hospital length of stay were compared based on the hospital unit where nesiritide therapy was initiated after multivariate adjustment for baseline differences in study populations. Results: Nesiritide was started in the ED in 1,613 patients (EDN group) and after admission to an inpatient unit in 2,687 patients (INN group). EDN patients had higher baseline systolic and diastolic blood pressure (both p < 0.001); while INN patients were more likely to be male and have baseline renal dysfunction (both p < 0.001). Nesiritide was initiated a median of 2.8 and 15.5 h after presentation in EDN and INN patients, respectively (p < 0.001). Compared to INN, EDN patients had a shorter adjusted mean total hospital length of stay (5.4 vs. 6.9 days; p < 0.001), were less likely to require transfer to the intensive care unit from another inpatient unit (odds ratio [OR]: 0.301; 95% confidence interval [CI]: 0.206–0.440), and were more likely to be discharged home (OR: 1.154; 95% CI: 1.005–1.325). Conclusions: Initiation of ADHF-specific therapy early, while the patient is in the ED, is associated with improved clinical outcomes.

Outpatient management of partial-thickness burns : Biobrane® versus 1% silver sulfadiazine

A randomized, prospective study comparing the use of Biobrane (group 1) with the use of 1% silver sulfadiazine (group 2) in treating 56 partial-thickness burn wounds was carried out in 52 outpatients with burns that comprised less than 10% of their total body surface area. The two groups were similar in age, gender, race, and extent of burn. Wounds of patients in group 1 (30) were compared with those of group 2 (26) for healing time, pain, compliance with scheduled visits, and costs. Infected and skin-grafted wounds were excluded from healing time analysis. Infection rates of the two groups were similar (three of 30 vs two of 26). One patient in each group underwent skin grafting. Healing times of group 1 wounds were significantly less than those of group 2 (10.6 +/- 0.8 vs 15.0 +/- 1.2 days, P less than .01). Using a pain scale of 1 to 5, Biobrane-treated patients averaged lower pain scores at 24 hours after the burn (1.6 +/- 0.8 vs 3.6 +/- 1.3 P less than .001) and used less pain medication. Compliance with scheduled outpatient visits was also improved in the Biobrane-treated group (88.6% vs 63.2% attendance, P less than .001). Idealized total treatment costs averaged

Early vasoactive drugs improve heart failure outcomes.

434 for patients in group 1 compared with

EMERGENCY DEPARTMENT MANAGEMENT OF ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN THE ELDERLY: THE MULTICENTER AIRWAY RESEARCH COLLABORATION

504 for patients in group 2. We conclude that when used on properly selected wounds, Biobrane therapy can significantly decrease pain and total healing time without increasing the cost of outpatient burn care. Improved patient compliance may be an added benefit.

Depression in geriatric ED patients: Prevalence and recognition

Vasoactive therapy is often used to treat acute decompensated heart failure (ADHF). The authors sought to determine whether clinical outcomes are temporally associated with time to vasoactive therapy (vasoactive time) in ADHF. Using the Acute Decompensated Heart Failure (ADHERE) Registry, the authors examined the relationship between vasoactive time and inpatient mortality within 48 hours of hospitalization. Vasoactive agents were used early (defined as <6 hours) in 22,788 (63.8%) patients and late in 12,912 (36.2%). Median vasoactive time was 1.7 and 14.7 hours in the early and late groups, respectively. In-hospital mortality was significantly lower in the early group (odds ratio, 0.87; 95% confidence interval, 0.79-0.96; P=.006), and the adjusted odds of death increased 6.8% for every 6 hours of treatment delay (95% confidence interval, 4.2-9.6; P<.0001). Early vasoactive initiation is associated with improved outcomes in patients hospitalized for ADHF.

Factors Associated With Relapse After Emergency Department Treatment for Acute Asthma

OBJECTIVES: To determine adherence of emergency department (ED) management of acute exacerbation of chronic obstructive pulmonary disease (COPD) to current treatment guidelines.

Effect of injection site on circulation times during cardiac arrest.

STUDY OBJECTIVE To determine the prevalence of depression in geriatric ED patients and to assess recognition of geriatric depression by emergency physicians. METHODS We conducted an observational survey of geriatric patients who presented to an urban, university-affiliated public hospital ED. A convenience sample of 259 patients aged 65 years or older were administered a brief, self-rated depression scale. Main outcome measures were prevalence of depression (using a predetermined cutoff score for detecting depression) and recognition of depression by the treating emergency physician, assessed by chart review. RESULTS Seventy subjects (27%; 95% confidence interval [CI], 22% to 32%) were rated as depressed. Depressed and nondepressed patients were not significantly different with regard to age, sex, race, or education. Forty-seven percent of nursing home residents were depressed, compared with 24% of those living independently (95% CI for difference of 23%, 6% to 41%). Patients who described their health as poor were also more likely to be depressed (33 of 65, 51%) than patients who reported their health to be good or fair (37 of 194, 19%) (95% CI for difference of 32%, 18% to 45%). Emergency physicians failed to recognize depression in all the patients found to be depressed on this scale (95% CI, 0 to 5%). CONCLUSION The prevalence of unrecognized depression in the geriatric ED patients we studied was high, especially in those who reported their health as poor. Use of a brief depression scale can aid recognition of depression in older patients, leading to appropriate referral and treatment.