Oral antibiotic use without consulting a physician: a survey of ED patients.

The purpose of our study was to determine the extent to which patients use antibiotics without consulting a physician and to examine patient characteristics associated with such oral antibiotic misuse. The study design was a prospective survey. The setting was a suburban, community, emergency department (ED). The participants were a convenience sample of oriented, ED patients who were enrolled during an 8-week period. Subjects provided written answers to standardized questions regarding their use of oral antibiotics over the 12 months preceding their ED visit. Categorical and continuous data were analyzed by chi-square and t-tests respectively. All test were 2-tailed with alpha set at 0.05. One thousand three hundred sixty three subjects were enrolled; 80% were White, 54% were female, 58% had attended college, 85% had a private physician, and 88% had health insurance. The mean age was 45 +/- 19 years. 43% of patients had used oral antibiotics within the past year. Twenty-two percent of patients indicated that their physicians routinely prescribed antibiotics for their cold symptoms. Seventeen percent of patients had taken "left-over" antibiotics without consulting their physician, most commonly for a cough (11%) or sore throat (42%), and much less frequently for urinary tract infection symptoms (0.7%). Women (19% versus 15% men; P =.04) and patients who attended college (19% versus 14% no college; P =.01) were more likely to have taken "left-over" antibiotics. A significant percentage of our ED patients had taken oral antibiotics without consulting a physician for symptoms frequently caused by viruses. Further study is warranted to examine whether local patterns of outpatient self-prescribing affect community oral antibiotic resistance.

The emergency department as a potential site for smoking cessation intervention: a randomized, controlled trial.

OBJECTIVE: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program. METHODS: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05. RESULTS: One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]. CONCLUSION: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.

Do diabetic patients have higher in-hospital complication rates when admitted from the emergency department for possible myocardial ischemia?

OBJECTIVE: To compare in-hospital complication rates for diabetic and nondiabetic patients admitted from the emergency department (ED) for possible myocardial ischemia. METHODS: This was a prospective, observational study of consecutive consenting patients presenting to a suburban university hospital ED during study hours with typical and atypical symptoms consistent with cardiac ischemia. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Inpatient records were reviewed by trained data abstractors to ascertain hospital course and occurrence of complications. Final discharge diagnosis of acute myocardial infarction (AMI) was assigned by World Health Organization criteria. Categorical and continuous data were analyzed by chi-square and t-tests, respectively. All tests were two-tailed with alpha set at 0.05. RESULTS: There were 1,543 patients enrolled who did not have complications at initial presentation; 283 were diabetic. The rule-in rate for AMI was 13.8% for nondiabetic patients and 17.7% for diabetic patients (p = 0.09). Times to presentation were similar for nondiabetic vs diabetic patients [248 minutes (95% CI = 231 to 266) vs 235 minutes (95% CI = 202 to 269); p = 0.32]. Nondiabetic patients tended to be younger [56.6 years (95% CI = 55.8 to 57.4) vs 61.6 years (95% CI = 60.2 to 63.1); p = 0.001] and were less likely to be female (34.3% vs 48.1%; p = 0.001). The two groups had similar prevalences for initial electrocardiograms diagnostic for AMI (5.5% vs 7.4%; p = 0.21). There was no significant difference between nondiabetic and diabetic patients for the occurrence of the following complications after admission to the hospital: congestive heart failure (1.3% vs 1.1%, p = 0.77); nonsustained ventricular tachycardia (VT) (1.3% vs 1.2%, p = 0.93); sustained VT (1.2% vs 1.1%, p = 0.85); supraventricular tachycardia (1.7% vs 3.2%, p = 0.12); bradydysrhythmias (1.9% vs 1.1%, p = 0.33); hypotension necessitating the use of pressors (0.9% vs 1.1%, p = 0.76); cardiopulmonary resuscitation (0.2% vs 0.7%, p = 0.10); and death (0.3% vs 0.7%, p = 0.34). One or more complications occurred with similar frequencies for patients in the two groups (6.3% vs 5.7%; p = 0.70). CONCLUSIONS: No statistically significant difference was found in the postadmission complication rates for initially stable diabetic vs nondiabetic patients admitted for possible myocardial ischemia. Based on these results, the presence or absence of diabetes as a comorbid condition does not indicate a need to alter admitting decisions with respect to risk for inpatient complications.

Safety and efficacy of diclofenac ophthalmic solution in the treatment of corneal abrasions.

STUDY OBJECTIVE: To determine whether the use of diclofenac ophthalmic solution is a safe and effective analgesic in the treatment of traumatic corneal abrasions in the emergency department. METHODS: We conducted a prospective, randomized, double-blinded, placebo-controlled clinical trial. Consenting consecutive patients with corneal abrasions who presented to a community-based ED from August through February 1998 were randomly assigned to receive either diclofenac or control vehicle drops. Pain relief was measured using a visual Numeric Pain Intensity Scale (NPIS) before and after treatment. Exclusion criteria were as follows: age younger than 18 years, pregnancy, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hours, minimal pain (NPIS score <3), and any allergy to diclofenac or nonsteroidal anti-inflammatory drugs. Patients were discharged with study drug or control vehicle solution, a topical antibiotic, oxycodone-acetaminophen as a rescue analgesic, and a pain diary. The outcome measurements were improvement in NPIS score 2 hours after treatment, use of oxycodone-acetaminophen, and occurrence of any adverse effects. RESULTS: Forty-nine patients were enrolled in the study; 25 received diclofenac and 24 received control vehicle drops. Both groups were similar in gender, age, pretreatment pain duration, NPIS score, and analgesic use. There was significantly greater improvement in the 2-hour NPIS score in the diclofenac group (3.1; 95% confidence interval [CI] 2.3 to 4) compared with the control group (1.0; 95% CI 0.1 to 2.0). The difference between the 2 groups was 2.1+/-1.3 (95% CI 0.8 to 3.4). There was a trend toward fewer patients taking rescue oxycodone-acetaminophen in the diclofenac group (20%; 95% CI 4% to 36%) versus the control group (42%; 95% CI 22% to 62%). Other than transient mild stinging, there were no complications associated with diclofenac use. CONCLUSION: Diclofenac ophthalmic solution appears to be a safe and effective analgesic in the treatment of traumatic corneal abrasions in the ED.

Droperidol for acute migraine headache.

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.

The etiology of cardiac arrest in children and young adults: special considerations for ED management.

Children and young adults rarely present to the emergency department (ED) in cardiac arrest. This review examines published series on nontraumatic, cardiac arrest for patients aged 1 to 45 years and discusses the differential diagnosis for cardiovascular collapse. Among the most common entities encountered are cardiac diseases (hypertrophic cardiomyopathy, myocarditis), airway diseases (pneumonia, epiglottitis, and asthma), epilepsy, hemorrhage (gastrointestinal bleeding, ectopic pregnancy), and drug toxicity (tricyclic antidepressants, cocaine). ED management of children and young adults in cardiac arrest requires an understanding of the heterogeneous pathophysiologic mechanisms and etiologies leading to cardiopulmonary dysfunction in these patients. The emergency physician should give particular focus to airway management for toddlers and preadolescents, because respiratory diseases predominate. When treating an adolescent or young adult, the resuscitation team should also consider toxic causes as well as occult hemorrhage. Management considerations unique to this patient population are discussed.

Fibrinolytic therapy in young women with acute myocardial infarction.

STUDY OBJECTIVE: Previous studies found that women with acute myocardial infarction (AMI) receive less aggressive therapy compared with men. We sought to determine the percentage of young women (12 hours after symptom onset) were the most common reasons for ineligibility.

Minor head trauma in anticoagulated patients.

OBJECTIVE: To determine the incidence of clinically significant intracranial injury in the anticoagulated patient suffering minor head trauma without loss of consciousness (LOC) or acute neurologic abnormality. METHODS: A retrospective chart review was performed based on a computerized search of electronic patient records from six community hospital EDs, one of which is a trauma center. Patients taking warfarin who sustained minor head trauma without LOC having no acute neurologic abnormalities treated from January 1994 to January 1996 were identified using a search of electronic ED records. Charts were reviewed for mechanism of injury, physical examination findings of head injury, and concomitant injury. Prothrombin time and head CT results were recorded if obtained. For those patients not receiving a head CT on ED evaluation, telephone follow-up was performed to determine outcome. RESULTS: There were 65 patients meeting inclusion criteria. Thirty-eight patients had prothrombin times obtained, with ranges from 12.0 sec to 30.7 sec. There was no intracranial injury found in any of the 39 patients having a head CT. Additionally, follow-up on the 26 patients who did not undergo CT scanning revealed no evidence of complications related to their head injuries. CONCLUSIONS: The incidence of clinically significant intracranial injury is extremely low in the anticoagulated patient suffering minor blunt head trauma without LOC or acute neurologic abnormality. CT scanning may not be necessary in these patients. Larger prospective studies are needed to confirm these findings.

Bolus i.v. nitroglycerin treatment of ischemic chest pain in the ED.

A prospective case series was conducted to demonstrate the safety and efficacy of intravenous nitroglycerin (i.v. NTG) boluses in the treatment of ischemic chest pain (CP) in the emergency department (ED). Patients with CP symptomatic after sublingual nitroglycerin (SL NTG) therapy with a systolic blood pressure (SBP) greater than 95 mmHg were included. Patients were treated with i.v. NTG boluses of 0.05 mg to 0.4 mg during a 1- to 2-minute period per a protocol based on the patient's prebolus SBP. This was followed by a maintenance infusion. Additional NTG boluses were repeated every 5 minutes as needed. The end point of treatment was the resolution of chest discomfort, thrombolysis, or a SBP less than 95 mmHg. There were 16 cases of CP. All 16 patients treated, ie, 5 with acute myocardial infarction and 11 with unstable angina showed significant decrease in chest discomfort after 1 to 2 boluses. Two of five with acute myocardial infarction and 9 of 11 patients with unstable angina had complete relief of chest pain after 1 to 4 boluses. There were no episodes of hypotension (SBP < 90 mmHg) in any of the 16 cases. The judicious use of i.v. NTG boluses administered during a 1- to 2-minute period, in the ED, appears safe and efficacious in patients with CP unresponsive to SL NTG therapy.