Oral versus intravenous corticosteroids in adults hospitalised with acute asthma.

BACKGROUND: Systemic corticosteroids are routinely used in the management of acute asthma, however the optimum route of administration for patients requiring hospitalisation is unclear. Intravenous (IV) corticosteroids are used in practice, but they may not offer any advantage over oral corticosteroids. AIM: To compare the efficacy of oral and IV administration of corticosteroids in the treatment of adults hospitalised with acute asthma. METHOD: Adults admitted to hospital for treatment of acute asthma were randomised to receive oral prednisolone 100 mg once daily or hydrocortisone 100 mg IV 6 hourly for 72 h following admission. All patients concurrently received inhaled corticosteroids and bronchodilators. Improvements in peak expiratory flow rate (PEF) from baseline were compared for 72 h. RESULTS: Forty-seven patients were randomized, 30 females, 17 males. Twenty-four received oral prednisolone and 23 received IV hydrocortisone. At baseline the oral and IV groups were similar (mean, SD) in age (38.3, 12.8 vs 37.3, 12.9, P=0.80) and initial percent predicted (PP) PEF (61, 16.7 vs 69, 13.0, P=0.11). After 72 h both groups had similar improvements in PEF (27%, 26 vs 27%, 19, P=0.96). CONCLUSION: Corticosteroids administered orally and IV had similar efficacy in the treatment of adults hospitalised with acute asthma.

Asthma in emergency departments: combined adult and paediatric versus paediatric only centres.

OBJECTIVE: To compare the management of paediatric patients with mild or moderate asthma in paediatric-only emergency departments (POEDs) to treatment in a mixed adult-child emergency departments (mixed EDs). METHODS: Prospective, observational study conducted in 36 Australian emergency departments (EDs) for 2 weeks in 2001. Children aged 1-15 years with acute asthma classified as mild or moderate severity. Details of demography, severity assessment, and type of treatment facility, treatment and disposition were collected. Analysis used descriptive statistics, comparison of proportions by chi2, and multiple logistic regression. RESULTS: Two-hundred and nine children were treated at POEDs and 257 at mixed EDs. The groups had similar severity. Spacers to deliver beta-agonists were used more frequently in POEDs (67.5% vs 24.2%; P < 0.01). Children treated at POEDs with a mild attack were more likely to be admitted (20.6% vs 9.5%; P < 0.02) and given salbutamol (82.8% vs 71.9%; P = 0.03). For children with moderate asthma, oral steroid prescription on hospital discharge was more common for those treated in a mixed ED (81.0% vs 95.7%; P = 0.01). Ipratropium bromide (IB) was widely used at both types of ED but more commonly used in mixed EDs (41.7% vs 54.9%; P < 0.01). There were no differences in length-of-stay, representation rate within one month and oral steroid use for attack. Less than 2/3 of children with mild asthma attacks received steroid treatment in the ED. CONCLUSION: Treatment was similar between the two types of ED. IB was overused in mild asthma and oral steroids were underused in moderate asthma, by both ED types. Spacers were under-utilized in mixed EDs.

Does routine use of the 15-lead ECG improve the diagnosis of acute myocardial infarction in patients with chest pain?

OBJECTIVE: It has been suggested that the use of additional electrocardiogram leads might improve the diagnostic sensitivity of this test, thus potentially expanding eligibility for thrombolysis for patients suffering myocardial infarction. The aims of this study were to evaluate the role of the 15-lead electrocardiogram in the emergency department chest pain population and to determine whether the routine use of the extra leads expands the group of patients eligible to receive thrombolysis. METHODS: Blinded, individual and independent analysis by two emergency physicians of paired 12- and 15-lead electrocardiograms from adult patients with a primary complaint of chest pain. The main outcome measure was the diagnosis of myocardial infarction eligible for thrombolysis. Data were analysed using descriptive statistics and kappa statistics for agreement between raters. RESULTS: 540 electrocardiograms (270 sets) were analysed. Myocardial infarction qualifying for thrombolysis was identified (by consensus) in 21 cases. In no case did the 15-lead electrocardiograph identify a myocardial infarction qualifying for thrombolysis that was not identified on the 12-lead electrocardiogram. CONCLUSION: In this study, the 15-lead electrocardiogram did not increase the number of thrombolysis-eligible myocardial infarctions identified when compared with the 12-lead electrocardiogram. This study is limited by the small patient sample size, and a large multicentre trial is recommended to compare the 12- and 15-lead electrocardiograms in the emergency department population where the incidence of posterior and right-sided myocardial infarction is ultimately known.

Experience with the use of continuous positive airway pressure (CPAP) therapy in the emergency management of acute severe cardiogenic pulmonary oedema.

BACKGROUND: Acute pulmonary oedema (APO) is a frequent cause of respiratory failure and a common reason for presentation to emergency departments (EDs). To date, no paper has been published on the application of continuous positive airway pressure (CPAP) therapy for a large broad-based patient group. AIM: To report our experience with the use of CPAP in severe APO oedema, with particular reference to safety, intubation rates and impact on EDs' resources. METHOD: A retrospective chart review was undertaken of 75 patients with acute severe pulmonary oedema who were treated with adjuvant CPAP in an urban teaching hospital ED. RESULTS: Three patients (4%) required subsequent endotracheal intubation and mechanical ventilation. The average duration of CPAP was 1.9 hours. Eighty nine per cent of patients experienced no adverse events while being treated with GPAP. Five patients failed to tolerate the tight fitting mask necessitating removal of CPAP, three patients experienced arrhythmias related to underlying cardiac disease and two patients experienced mild transient hypotension. Seventy one per cent of patients were discharged from the ED to general medical wards. The in-hospital mortality for patients treated with CPAP was 15%. CONCLUSION: This series has demonstrated that CPAP therapy delivered via a face mask for the treatment of acute severe APO is safe and effective when applied to a broad range of patients. We recommend the use of CPAP therapy for all suitable patients presenting in severe APO irrespective of age or underlying pulmonary disease.

Is a standard regime for anticoagulation with heparin in unstable angina adequate?

AIM: To establish the proportion of patients with unstable angina in whom adequate anticoagulation is achieved using a standard regime of intravenous heparin. METHOD: A prospective series of 108 Emergency Department attendees over a six-month period with a clinical diagnosis of unstable angina for whom anticoagulation with heparin was prescribed were included in the study. The standard regime was a 5000 unit bolus followed by an intravenous infusion of 1000 units per hour (1200 units if the patient's weight was greater than 80 kg), with subsequent adjustments being made by reference to a nomogram. The activated partial thromboplastin time (APTT) was measured at six and 12 hours after treatment began. Two commonly used criteria for adequate heparinisation were compared: 1. APTT greater than 1.5 times control and 2. APTT in the range of 60-85 seconds. RESULTS: There were valid data for 90 patients at six hours and 79 at 12 hours. Compared to the criterion for adequate anticoagulation of APTT greater than 1.5 times the control, 25% of patients were subtherapeutic at six hours and 12% at 12 hours. Compared to the criterion APTT greater than 60 seconds, 53% of patients were subtherapeutic at 6 hours and 47% at 12 hours. At 6 hours, 26% of patients were over-anticoagulated as defined as APTT greater than 85 seconds. This had reduced to 13% by 12 hours. CONCLUSIONS: In the context of recent research suggesting that an APTT of greater than 1.5 times the control is sufficient to reduce complications in unstable angina, our results demonstrate that a standard regime of heparinisation will achieve this goal in the majority of patients within 6 hours of starting heparin therapy. However, if an APTT of 60-85 seconds is the goal, this standard regime is inadequate.

Impact of general practitioners' referral letters to an emergency department.

INTRODUCTION: We sought to determine the impact of general practitioner communication on the efficient management of patients who present to the emergency department. Casemix, severity, time of presentation, the quality of the letter and the reception of a telephone call were considered. METHOD: All consecutive patients presenting to the emergency department of Mornington Peninsula Hospital (Frankston) for one month in 1992 were included in this survey. The methodology is summarised in Figure 1. RESULTS: The referral letter made no difference to patients' waiting time and time spent in the department and a non significant difference in communication back to the general practitioner. This was found despite the quality of the referral letter, the time of presentation, and the diagnosis. The general practitioners' telephone call, however, decreased significantly the patient's waiting time. Investigations that were reported in the general practitioners' letters and not repeated by the emergency department resulted in a direct saving of $2604 for the month of the study. High interrater reliability was discovered in the rating of letters by six general practitioners. DISCUSSION: Despite the ability of general practitioners to select appropriate cases for referral, only the telephone call results in a quantifiable benefit for patients who attend their general practitioner. The high inter-rater reliability affirms the use of referral letters as audit tools in general practice. Better practical use could be made of general practitioners' referral communication to the emergency department.

Survey of Australian emergency physicians' expectations of general practitioner referrals.

This paper reports the first study of Australian emergency physicians which concentrates on their relationship with general practitioners. A self-administered questionnaire was mailed to every known fellow and senior trainee of the Australasian College of Emergency Medicine working in Victoria, Australia. Good response rates were achieved (97% from fellows, 78% from trainees). Referral letters from general practitioners were always read by 99% of respondents. Telephone calls from general practitioners were found to be desirable for imparting details of social history or other qualitative information and for determining the appropriateness of the referral. The list of patients' current medication and the details of any emergency treatment administered by the general practitioner were almost universally considered essential inclusions in all urgent referral letters. Other items of information were considered to be influenced by the particular patient presentation. The majority of respondents (87%) felt that a written management plan had some influence on the patient's management in their emergency department. Eighty nine per cent of respondents stated that they always or usually responded to general practitioners' communications. The outcome for patients attending emergency departments with referral letters warrants study. If a good referral letter is seen to be of value in terms of more accurate diagnosis, quicker patient processing, less investigations and better responses, then general practitioners will be encouraged to write better letters. The results of this study offer a useful definition of inappropriate referral to the emergency department and it may now be possible to investigate any link between poor referral letters and inappropriate referrals.

Tension pneumoperitoneum after cardiopulmonary resuscitation.

OBJECTIVE: To increase awareness of the unusual complication of pneumoperitoneum after cardiopulmonary resuscitation. CLINICAL FEATURES: A 57-year-old male farmer with a history of chronic renal failure and heart disease, as well as severe oesophageal reflux for which fundoplication had been performed, developed a tension pneumoperitoneum after cardiopulmonary resuscitation. This resulted in lower limb cyanosis and an erection, a previously unreported complication. INTERVENTION AND OUTCOME: The tension was relieved by uncapping a peritoneal dialysis catheter that was in situ. The cyanosis and erection resolved immediately, suggesting that the tension pneumoperitoneum had caused significant venous obstruction. A 3 cm defect in the posterior wall of the stomach was repaired. CONCLUSION: The likelihood of pneumoperitoneum is reduced if standard guidelines for cardiopulmonary resuscitation are adhered to.

Whole lung pulmonary angiography in the intensive care unit with two portable chest x-rays.

Suspected massive pulmonary embolism requires urgent, accurate diagnosis. We describe a technique for pulmonary angiography in the ICU. Four patients admitted with suspected pulmonary embolism had fulminating cardiorespiratory failure with support requirements precluding transfer. Each patient had a flow-directed pulmonary angiography catheter inserted into the pulmonary artery. In two catheter positions, 25 ml of iopamidol 612 mg/ml was delivered from a portable angiographic injector at a flow of 20 ml/sec. A portable x-ray was taken immediately before completion of syringe excursion. Major central pulmonary emboli were seen in three patients and a negative angiogram was obtained on the fourth. Two of the three positive diagnoses were confirmed at pulmonary embolectomy. The negative diagnosis was confirmed at autopsy. Pulmonary angiography via a flow-directed catheter enabled precise and rapid diagnosis of pulmonary embolism in patients too ill to transfer for formal angiography.

Serum erythropoietin (ESF) titers in anemia of chronic renal failure.

ESF titers were determined in 99 patients of various stages of chronic renal failure, by using the fetal mouse liver cell bioassay. Of these patients 45 were receiving conservative therapy and 54 on maintenance hemodialysis. ESF levels were significantly below normal in both groups of patients. A significant inverse relationship was found between hemoglobin concentration and ESF level in the predialysis patients with chronic glomerulonephritis. No correlation was found between both parameters in the predialysis patients with chronic nonglomerular renal disease. A significant positive correlation was found between hemoglobin concentration and ESF level in nephric dialysis patients who were transfusion independent. Transfusion-dependent nephric dialysis patients had lower hemoglobin concentrations and lower ESF levels before transfusion than did nephric dialysis patients who were transfusion independent. In nephric dialysis patients ESF levels fell sharply after blood transfusion, whereas in anephric dialysis patients such a physiologic ESF response was not found. It was concluded that despite the presence of an absolute ESF deficiency in all anemia uremic patients, this anemia cannot be explained by ESF deficiency alone. The increasing degree of anemia found in predialysis patients with deteriorating renal function appears to be primarily caused by factors other than ESF deficiency, the most likely being accumulation of uremic inhibitors of erythropoiesis. In dialysis patients in whom inhibitor levels are relatively homogeneous, the degree of anemia appears to be directly related to the residual capability of the kidney or the extrarenal sites to produce ESF.

Serum erythropoietin (EST) titers in anemia.

Erythropoietin (ESF) titers were determined in sera from patients with different types of anemia using the fetal mouse liver cell bioassay. An inverse relationship was found between hemoglobin concentration and ESF titer. However, ESF titers differed markedly between patients at comparable degrees of anemia. Several groups of patients were distinguished on the basis of the activity of their erythroid bone marrow. In each of these groups, a significant negative correlation was found between the hemoglobin concentration and the logarithm of the ESF titer. ESF titers in patients with pure red cell aplasia were fourfold higher than those in patients with iron-deficiency anemia and tenfold higher than those in patients with megaloblastic anemia and homozygous sickle cell anemia at comparable hemoglobin concentrations. Following the initiation of specific therapy in patients with pernicious anemia and patients wit iron-deficiency anemia, serum ESF titers were found to decrease prior to any substantial rise in hemoglobin concentrations. In the patients with pernicious anemia, the lowest ESF levels were found 1 day after administration of vitamin B12, whereas in the patients with iron-deficiency anemia, the lowest ESF levels were reached in the second week of oral iron therapy. ON the basis of these data it was concluded that serum ESF titers in anemic patients are not only inversely related to the hemoglobin concentration but also to the activity of the erythroid bone marrow.

Serum erythropoietin (ESF) titers in polycythemia.

Serum ESF titers were measured in 42 polycythemic patients using the fetal mouse liver cell bioassay. ESF titers in patients with secondary polycythemia differed significantly from those in patients with polycythemia vera (p less than 0.0001). Among the 21 patients with secondary polycythemia, 1 patient had an ESF titer less than 10 mU/ml (the lower limit of sensitivity) and 20 had ESF titers that ranged between 11 and 112 mU/ml, with a mean titer of 56 mU/ml. Among the 21 patients with polycythemia vera, 13 patients had ESF titers less than 10 mU/ml and 8 had ESF titers ranging between 12 and 55 mU/ml, with a mean titer of 26 mU/ml. The mean hemoglobin concentration in the 8 patients with ESF titers greater than 10 mU/ml was significantly below that in the 13 polycythemia vera patients with ESF titers less than 10 mU/ml (p less than 0.03). If ESF titers less than 10 mU/ml had been indicative of polycythemia vera and ESF titers greater than 10 mU/ml had been indicative of secondary polycythemia in patients with hemoglobin concentrations greater than 17.7 g/dl, but not indicative of either condition in patients with hemoglobin concentrations less than 17.7 g/dl, 71.5% of the polycythemic patients in this study would have been diagnosed correctly, 9.5% incorrectly, and in the 19% the diagnosis would have remained uncertain. It was concluded that measurement of serum ESF titers using this in vitro bioassay can be of clinical importance in differentiating between polycythemia vera and secondary polycythemia.

Comparison of the hemagglutination inhibition assay kit for erythropoietin (ESF) with the fetal mouse liver cell bioassay in vitro.

The commercially available hemagglutination inhibition (HAI) assay kit for erythropoietin (ESF) was compared with the fetal mouse liver cell (FMLC) bioassay. No correlation was obtained ESF levels determined by both methods in a variety of pathologic sera. The HAI kit showed a great batch variability. Significant immunoreactivity was found in those fractions of a normal human serum and a human urinary ESF preparation that were not active in the FMLC bioassay. A very poor recovery of immunoreactivity was found when the international reference preparation for erythropoietin (second IRPE) was added to a normal human serum.