Acutely decompensated heart failure: opportunities to improve care and outcomes in the emergency department.

Each year about 550,000 new patients are diagnosed as having congestive heart failure, which for acutely symptomatic patients is also referred to as acutely decompensated heart failure. The incidence of congestive heart failure is approximately 10 per 1000 for Americans over the age of 65 years. Men and women are affected in equal numbers, and 5-year mortality has been reported to be as high as 50%. Increased longevity increases the likelihood that heart failure will develop as a consequence of pathophysiologic processes that gradually weaken the myocardium and the vascular system. Patients who present to the emergency department with complaints of shortness of breath, dyspnea on exertion, increasing lower extremity edema, and/or worsening fatigue should have heart failure included in the differential diagnosis. Heart failure patients experiencing symptoms consistent with cardiac ischemia, hypoxia, potentially lethal arrhythmias, marked hypertension, or hypotension should be immediately triaged to a critical care area. The approval of nesiritide by the U.S. Food and Drug Administration in 2001 has stimulated the development of revisions in strategies for the emergency department treatment of acute decompensated heart failure patients. The early use of nesiritide, along with topical nitroglycerin and a loop diuretic, may lead to more rapid resolution of these patients' acute symptoms and hemodynamic dysfunction.

Nursing home-acquired pneumonia: an emergency department treatment algorithm.

Nursing home-acquired pneumonia (NHAP) is a leading cause of morbidity, hospitalization, and mortality among older nursing home residents. Too often, these patients are erroneously grouped with cases of community-acquired and hospital-acquired pneumonia. Yet, they differ in terms of most common pathogens, significant underlying disease, impaired functional and cognitive status, and poor nutrition. The NHAP emergency department treatment algorithm presented here shows that an important decision for initial care in the emergency department (ED) is whether the patient should return to the nursing home. This decision often is based on the facility's ability to administer parenteral antibiotics, and care for co-morbidities and complications. Cephalosporins are the foundation of initial treatment of NHAP in the ED, and are combined with other antibiotics in anticipation of the most likely pathogens and treatment variables discussed here. It is hoped the NHAP treatment algorithm will contribute to improved outcomes.

Emergency department evaluation and treatment of patients with ST-segment elevation myocardial infarction.

Acute coronary syndrome (ACS) identifies a set of clinical presentations with a common etiology. This entity accounts for more deaths in the United States than any other disease or form of injury. Early identification and management has been shown to substantially reduce the morbidity and mortality associated with ACS. As a result of efforts by several organizations to inform the public of the importance of immediately responding to signs and symptoms of ACS, a growing percentage of ACS patients are seeking emergency department care in a timely manner. Patients with ST segment elevation myocardial infarction (STEMI) are among the most vulnerable ACS patients. Immediate triage to a properly equipped and staffed ACS area within the ED is essential. Some therapeutic measures can be implemented while the initial assessment is underway. Additional therapeutic interventions will be dictated by the results of history, physical examination, electrocardiogram, serum marker measurements, radiologic and ultrasound results. Protocols designed to assist with the management of STEMI patients improve the speed and accuracy of treatment while helping to reduce medical errors. Protocols should include stimuli that will encourage timely, appropriate interfacility transfers, personal physician involvement, and cardiology consultation. The rapid pace of advancement in medical knowledge surrounding STEMI management necessitates monitoring of compliance with protocols and periodic revision to achieve optimal outcomes for patients.

Facilitating optimal care of acute coronary, cerebrovascular and peripheral vascular syndromes in the emergency department: the role of oral antiplatelet therapy.

The benefits of aspirin use in the emergent care of MI and stroke have been well established. Recent studies have further demonstrated the importance of antiplatelet therapy in the acute setting, primarily with the use of intravenous glycoprotein IIb/IIIa receptor inhibitors. Aspirin and the thienopyridines (ticlopidine and clopidogrel) are oral antiplatelet agents that interfere with platelet activation in complementary, but separate pathways. Combination therapy of clopidogrel and aspirin has demonstrated benefit for the management of acute coronary syndromes, ischemic cerebrovascular disease and peripheral vascular disease in several large trials. This article reviews the pathophysiology of platelet activation, landmark trials on oral antiplatelet agents, and the current recommendation for the use of oral antiplatelet agents in the emergency department.

Prehospital management of cardiac arrest: how useful are vasopressor and antiarrhythmic drugs?

Out-of-hospital resuscitation protocols for patients suffering cardiac arrest have historically included cardiopulmonary resuscitation, defibrillation, and rapid transport to a hospital. For many years, use of drugs to improve myocardial perfusion or to correct arrhythmias that occur during cardiac arrest has been part of prehospital efforts to revive patients in ventricular tachycardia or ventricular fibrillation. Use of some of these drugs, however, may be based more on tradition than on well-documented evidence of efficacy. The authors reviewed pertinent data on the vasopressors epinephrine and vasopressin and the antiarrhythmics amiodarone and lidocaine to evaluate the usefulness of these drugs in cardiac arrest. They found little clinical data supporting the prehospital use of lidocaine in cardiac arrest, and despite a great deal of laboratory and clinical data addressing the efficacy of epinephrine, there is no large, randomized, controlled clinical trial supporting its use. Data on amiodarone and vasopressin support the use of these drugs in out-of-hospital resuscitation efforts.