Michelle Blanda

Multicenter study of patients with angiotensin- converting enzyme inhibitor-induced angioedema who present to the emergency department

BACKGROUNDnRecent data are lacking about the number of patients with angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema who present to the emergency department (ED). Current management of the condition and clinical outcomes also are not known.nnnOBJECTIVEnTo describe the clinical epidemiology of ACEI-induced angioedema in patients who present to the ED.nnnMETHODSnWe performed a medical record review of ACEI-induced angioedema in patients who presented to 5 EDs in the Emergency Medicine Network. A structured data abstraction form was used to collect each patients demographic factors, medical history, and details about the angioedema that prompted the ED visit. The medical record review also focused on treatment provided in the ED and subsequent need for hospitalization.nnnRESULTSnWe identified a total of 220 patients with ACEI-induced angioedema. The frequency of ACEI-induced angioedema among all patients with angioedema who presented to the ED was 30% (95% confidence interval, 26%-34%). The annual rate of visits for ACEI-induced angioedema was 0.7 per 10,000 ED visits. The most frequent presenting signs were shortness of breath, lip and tongue swelling, and laryngeal edema. Most patients (58%) were sent home directly from the ED, whereas 12% were regular inpatient admissions, 11% were admitted to the intensive care unit, and 18% were admitted under observation status (<24 hours). Pharyngeal swelling and respiratory distress were independent predictors of hospital admission and longer length of stay.nnnCONCLUSIONnACEI-induced angioedema accounted for almost one-third of angioedema treated in the ED, although it remains a rare ED presentation. A subgroup of these patients still needs inpatient hospitalization for management of upper airway angioedema.

Posterior Epistaxis: Clinical Features and Acute Complications

STUDY OBJECTIVEnTo describe the clinical features, evaluate the incidence of serious complications, and identify factors associated with rebleeding in adults with acute posterior epistaxis.nnnDESIGNnRetrospective chart review.nnnSETTINGnUniversity-affiliated community teaching hospital.nnnPARTICIPANTSnWe studied 88 episodes of posterior epistaxis in 81 patients (mean age, 64.3 years; range, 27 to 96 years) who were treated in the emergency department and hospitalized during a 6-year period. Inclusion criterion was active hemorrhage into the posterior pharynx without identifiable anterior bleeding or severe nasal hemorrhage refractory to anterior packing. Patients with anterior epistaxis were excluded.nnnRESULTSnPosterior epistaxis accounted for 5% of all cases of epistaxis. The most common factors associated with posterior epistaxis were a history of hypertension in 39 patients (48%) and previous epistaxis in 30 (37%). Of 57 patients who reported duration of epistaxis, 39 (68.4%) had nasal hemorrhage for less than 12 hours before ED presentation, and 13 patients (22.8%) had nasal bleeding that lasted more than 24 hours. Bleeding was recorded as moderate or severe for 88% of patients. All patients were treated with posterior nasal packing in the ED (73% with traditional gauze packing, 15% with balloon, and 12% with tampon). After admission, 16 patients (19.8%) required surgical intervention, 17 (21%) experienced acute sinusitis, 10 (12.3%) received blood transfusions, and 3 (3.7%) were intubated. Rebleeding occurred in 24 patients (29.6%), with 13 episodes (44.1%) occurring less than 24 hours after admission. Factors associated with rebleeding were posterior epistaxis described as severe (OR, 2.53; 95% CI, .88 to 7.39; chi 2 = 2.84, 1 df, P = .92) and pack removal within 48 hours after admission (OR, 3.07; 95% CI, .98 to 9.88; chi 2 = 3.66, 1 df, P = .056). Factors that failed to predict rebleeding included age, prior hypertension, anticoagulant use, vital signs, and type of posterior pack used (gauze or balloon).nnnCONCLUSIONnAlthough posterior epistaxis is an uncommon otolaryngologic emergency, many patients experience clinically significant complications. Rebleeding was associated with severe posterior epistaxis and pack removal within 48 hours after admission.

Prospective Multicenter Study of Acute Asthma in Younger Versus Older Adults Presenting to the Emergency Department

OBJECTIVES: To describe acute asthma in younger versus older adults presenting to the emergency department (ED).

Comparison of Intramuscular Triamcinolone and Oral Prednisone in the Outpatient Treatment of Acute Asthma: A Randomized Controlled Trial

STUDY OBJECTIVEnTo determine whether a one-time dose of triamcinolone diacetate, 40 mg intramuscular (i.m.), given to adult patients treated in the emergency department for mild to moderate exacerbation of asthma would decrease the rate of relapse during the following week, compared with a nontapering course of oral prednisone, 40 mg/day over 5 days.nnnMETHODSnA randomized, double-blind, controlled clinical trial was conducted at two university-affiliated community teaching hospitals with a combined annual census of 97,000. Patients were eligible if they were between the ages of 18 and 50 years, had an initial peak expiratory flow rate of less than 350 L/minute, and were to be discharged from the ED taking steroids. Patients were randomly assigned to receive either triamcinolone (40 mg i.m.) and placebo tablets or a placebo injection and prednisone (40 mg/day orally for 5 days). Patients were instructed to use a beta-agonist metered-dose inhaler, to continue other routine medications, to complete symptom diary cards, and to return in 7 to 10 days for follow-up. The main outcome measure was relapse, which was defined as an unscheduled visit to a physicians office or ED for worsening or persistent symptoms within 7 days of the initial ED visit.nnnRESULTSnA total of 168 patients were initially enrolled; 6 patients were withdrawn for protocol violations and 8 because they could not be contacted for follow-up. A total of 154 patients were available for outcome analysis, 78 in the triamcinolone group and 76 in the prednisone group. There were no differences between the two patient groups with regard to demographics, smoking history, weight, or symptom severity. Mean initial peak flows were 244+/-64 L/minute for the triamcinolone group and 245+/-83 L/minute for the prednisone group. Fifty percent of the study patients were current smokers. The relapse rates were 9.0% (7/78) in the triamcinolone group and 14.5% (11/76) in the prednisone group (P=.29). The absolute difference in relapse rates was 5.5% (95% confidence interval [CI], 4.6% to 15.6%). There was no difference in symptom frequency or severity between the two groups during the first 5 days of outpatient treatment. Analysis between the groups stratified for smoking showed no difference in relapse rate between smokers and nonsmokers.nnnCONCLUSIONnA single dose of triamcinolone diacetate, 40 mg i.m., produced a relapse rate similar to that of prednisone, 40 mg/day orally for 5 days, after ED treatment of mild to moderate exacerbations of asthma. Intramuscular triamcinolone would appear to be an attractive alternative when compliance with a daily oral regimen is of concern.

Short-term Functional Decline and Service Use in Older Emergency Department Patients With Blunt Injuries

BACKGROUNDnInjuries are a common reason for emergency department (ED) visits by older patients. Although injuries in older patients can be serious, 75% of these patients are discharged home after their ED visit. These patients may be at risk for short-term functional decline related to their injuries or treatment.nnnOBJECTIVESnThe objectives were to determine the incidence of functional decline in older ED patients with blunt injuries not requiring hospital admission for treatment, to describe their care needs, and to determine the predictors of short-term functional decline in these patients.nnnMETHODSnThis institutional review board-approved, prospective, longitudinal study was conducted in two community teaching hospital EDs with a combined census of 97,000 adult visits. Eligible patients were > or = 65 years old, with blunt injuries <48 hours old, who could answer questions or had a proxy. We excluded those too ill to participate; skilled nursing home patients; those admitted for surgery, major trauma, or acute medical conditions; patients with poor baseline function; and previously enrolled patients. Interviewers collected baseline data and the used the Older Americans Resources and Services (OARS) questionnaire to assess function and service use. Potential predictors of functional decline were derived from prior studies of functional decline after an ED visit and clinical experience. Follow-up occurred at 1 and 4 weeks, when the OARS questions were repeated. A three-point drop in activities of the daily living (ADL) score defined functional decline. Data are presented as means and proportions with 95% confidence intervals (CIs). Logistic regression was used to model potential predictors with functional decline at 1 week as the dependent variable.nnnRESULTSnA total of 1,186 patients were evaluated for eligibility, 814 were excluded, 129 refused, and 13 were missed, leaving 230 enrolled patients. The mean (+/-SD) age was 77 (+/-7.5) years, and 70% were female. In the first week, 92 of 230 patients (40%, 95% CI = 34% to 47%) had functional decline, 114 of 230 (49%, 95% CI = 43% to 56%) had new services initiated, and 76 of 230 had an unscheduled medical contact (33%, 95% CI = 27% to 39%). At 4 weeks, 77 of 219 had functional decline (35%, 95% CI = 29% to 42%), 141 of 219 had new services (65%, 95% CI = 58% to 71%), and 123 of 219 had an unscheduled medical contact (56%, 95% CI = 49% to 63%), including 15% with a repeated ED visit and 11% with a hospital admission. Family members provided the majority of new services at both time periods. Significant predictors of functional decline at 1 week were female sex (odds ratio [OR] = 2.2, 95% CI = 1.1 to 4.5), instrumental ADL dependence (IADL; OR = 2.5, 95% CI = 1.3 to 4.8), upper extremity fracture or dislocation (OR = 5.5, 95% CI = 2.5 to 11.8), lower extremity fracture or dislocation (OR = 4.6, 95% CI = 1.4 to 15.4), trunk injury (OR = 2.4, 95% CI = 1.1 to 5.3), and head injury (OR = 0.48, 95% CI = 0.23 to 1.0).nnnCONCLUSIONSnOlder patients have a significant risk of short-term functional decline and other adverse outcomes after ED visits for injuries not requiring hospitalization for treatment. The most significant predictors of functional decline are upper and lower extremity fractures.

EMTS' K NOWLEDGE R EGARDING T RANSMISSION OF I NFECTIOUS D ISEASE

Objective. To describe EMTs knowledge of CDC universal precaution guidelines and transmission routes for human immunodeficiency virus (HIV), hepatitis, meningitis, and tuberculosis (TB) and their perceived exposures to and concerns about these diseases. Methods. A convenience sample of EMTs were surveyed at mandatory continuing education meetings in a midwest community (pop. 523,191) between October 1 and November 30, 1996. The survey contained 101 questions about knowledge of universal precautions, transmission routes, postexposure actions, personal and family concerns, and demographics. Correct responses were based on CDC guidelines, and incorrect answers were added. Results. Four hundred of 425 surveys (94%) were returned. Eighty-one percent of the EMTs were full-time paramedics with 9.4 (95% CI 8.7–10.0%) years of experience. Seventy-five percent reported HIV, hepatitis, and TB education, while 57% reported meningitis education within the preceding year. Ninety-one percent knew universal precautions should be used with every patient. Needlestick was correctly reported as a transmission route for HIV (98%) and hepatitis (92%), but incorrectly reported for TB (37%) and meningitis (60%). Tuberculosis (94%) and meningitis (64%) were correctly identified as airborne. Thirty-four percent of the EMTs reported inadequate knowledge of infectious diseases (IDs) to protect themselves. Their perceived exposure for all four diseases ranged from 65% to 73%, but only 10–40% reported follow-up testing. Families concern about EMTs exposure was reported as moderate to high by 63% of the respondents. Conclusions. There appears to be a need for continuing education for EMTs focusing on the routes of transmission of IDs, their chance of exposure, appropriate use of protective equipment, and the need for follow-up testing. This may allow more effective use of protective equipment and allay fears of EMTs and their families.

When the business of healthcare overshadows the value of academic faculty: A community's loss of a residency program

gestion amount alone. Although reported overdose cases to date have presented only mild symptoms, it is not yet known if larger doses may increase the risk of severe consequences. Until more experiences of apixaban overdose cases are at hand, we recommend careful monitoring of such patients until coagulation tests have normalized. Still, these three cases illustrate a general benign course of acute ingestions similar to other anticoagulant ingestions.