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BACKGROUND Emergency department (ED) patients with uncomplicated atrial fibrillation (AF) of less than 48 hours may be safely managed with rhythm control. Although both chemical-first and electrical-first strategies have been advocated, there are no comparative effectiveness data to guide clinicians. METHODS At six urban Canadian centers, ED patients ages 18 to 75 with uncomplicated symptomatic AF of less than 48 hours and CHADS2 score of 0 or 1 were randomized using concealed allocation in a 1:1 ratio to one of the following strategies: 1) chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or 2) electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within 4 hours of arrival. Secondary outcomes included ED length-of-stay (LOS); prespecified ED-based adverse events; and 30-day ED revisits, hospitalizations, strokes, deaths, and quality of life (QoL). RESULTS Eighty-four patients were analyzed: 41 in the chemical-first group and 43 in the electrical-first group. Groups were balanced in terms of age, sex, vital signs, and CHADS2 scores. All patients were discharged home, with 83 (99%) in sinus rhythm. In the chemical-first group, 13 of 41 patients (32%) were discharged within 4 hours compared to 29 of 43 patients (67%) in the electrical-first group (p = 0.001). In the chemical-first group, the median ED LOS was 5.1 hours (interquartile range [IQR] = 3.5 to 5.9 hours) compared to 3.5 hours (IQR = 2.4 to 4.6 hours) in the electrical-first group, for a median difference of 1.2 hours (95% confidence interval = 0.4 to 2.0 hours, p

Objectives In non–emergency department (ED) settings, women with atrial fibrillation and flutter (AFF) have different presentations, treatments, and outcomes than men: they are older, less likely to be treated with rhythm control strategies or appropriate anticoagulation, and more likely to have strokes. This has not been investigated in ED patients. Methods Records from consecutive ED patients from January 1 to December 31, 2009, with electrocardiogram-proven AFF at two urban hospitals were collected. Review of administrative and clinical data identified patient demographics, clinical characteristics, comorbidities, and ED treatments. The regional ED database was queried to determine 30-day and 1-year follow-up visits, and the provincial vital statistics database was referenced to obtain 30-day and 1-year mortality; all outcomes were stratified by sex. The primary outcome, which reflected overall appropriateness of ED care, was the proportion of patients who were discharged home at their index ED visits, who then had unscheduled 30-day ED revisits. Secondary outcomes included the proportion of eligible patients who underwent acute rhythm control strategies and the proportion of high-risk patients who had previously inadequately anticoagulation strategies corrected by the emergency physician. Additional outcomes included the ED length of stay (LOS) and 30-day and 1-year rates of stroke and death. Results A total of 1,112 records were reviewed: 470 women (42.3%) and 642 men. Women were a median 8 years (interquartile range = 3 to 13 years) older than men, had higher rates of cardiovascular comorbidities, and were more likely to present with atypical symptoms such as weakness or dyspnea. On their index ED visits, 50.2% of women and 41.3% of men were admitted. At 30 days, 39 of 234 (16.7%) women and 55 of 377 (14.6%) men who were discharged at their index ED visits had made revisits, for a risk difference of 2.1% (95% confidence interval = –3.9% to 8.5%). There were no apparent sex differences in the use of acute rhythm control or in the appropriateness of anticoagulation decisions. ED LOS was similar between women and men, as were 30-day and 1-year stroke or death rates. Conclusions Female ED AFF patients were older, had more comorbidities, and were more likely to be admitted. However, the overall management and outcomes, including 30-day revisits, appeared to be similar to that of males, indicating that there appeared to be little sex-based discrepancy in ED care and outcomes. Resumen Existen Diferencias Respecto al Sexo en los Perfiles de Riesgo y Demograficos de los Pacientes con Flutter y Fibrilacion Auricular del Servicio de Urgencias, Pero Aparentemente no Existen Diferencias en el Manejo en el SU o los Resultados Objetivos En escenarios distintos al servicio de urgencias (SU), las mujeres con flutter y fibrilacion auricular (FFA) tienen diferentes presentaciones, tratamientos y resultados que los hombres: ellas son de mayor edad, tienen menor probabilidad de ser tratadas con estrategia de control de ritmo o anticoagulacion apropiada, y su probabilidad de tener un ictus es mayor. Esto no ha sido investigado en los pacientes del SU. Metodologia Desde el 1 de enero al 31 de diciembre de 2009, se recogieron de forma consecutiva las historias clinicas de los pacientes de SU de 2 hospitales que presentaban FFA comprobados electrocardiograficamente. La revision de los datos clinicos y administrativos identifico las variables demograficas del paciente, las caracteristicas clinicas, las comorbilidades y los tratamientos en el SU. La base de datos del SU regional fue necesaria para determinar las visitas de seguimiento a los 30 dias y al ano, y la base de datos provincial de las estadisticas de defuncion para obtener la mortalidad a los 30 dias y al ano; todos los resultados se estratificaron por el sexo. El resultado principal, que reflejo las adecuaciones globales de la atencion del SU, fue la proporcion de pacientes que fueron dados de alta al domicilio en la visita indice al SU y que tuvieron una revisita no programada al SU en los primeros 30 dias. Los resultados secundarios incluyeron: 1) la proporcion de pacientes elegibles en los que se llevo a cabo un estrategia urgente de control del ritmo; y 2) la proporcion de pacientes de alto riesgo que tuvieron estrategias previas de anticoagulacion inadecuadas corregidas por el urgenciologo. Los resultados adicionales incluyeron el tiempo de estancia (TDE) en el SU y las tasas de ictus y mortalidad a los 30 dias y al ano. Resultados Se revisaron 1.120 historias clinicas: 470 mujeres (42,3%) y 642 hombres. Las mujeres eran una mediana de 8 anos (rango intercuartilico [RIC] 3 a 13 anos) mayores que los hombres, tuvieron mayor frecuencia de comorbilidades cardiovasculares y mayor probabilidad de presentarse con sintomas atipicos como la debilidad o la disnea. En la visita indice al SU, 50,2% de las mujeres y 41,3% de los hombres fueron ingresados. A los 30 dias, 39 de 234 mujeres (16,7%) y 55 de 377 hombres (14,6%) dados de alta en la visita indice al SU tuvieron una revisita, con una diferencia de riesgo de un 2,1% (IC95% = -3,9% a 8,5%). No hubo diferencias aparentes respecto al sexo en el control urgente del ritmo o en las adecuaciones de las decisiones de anticoagulacion. El TDE en SU fue similar entre hombres y mujeres, asi como la tasas de muerte e ictus a los 30 dias y al ano. Conclusiones Los pacientes de sexo femenino con FFA atendidas en el SU fueron de mayor edad, tuvieron mas comorbilidades y una mayor probabilidad de ser ingresadas. Sin embargo, los resultados y el manejo global, incluyendo las revisitas a los 30 dias, parecieron ser similares, indicando que parecia existir una discrepancia pequena basada en el sexo en la atencion del SU y los resultados.

To develop a clinical prediction rule to identify patients who can be safely discharged one hour after the administration of naloxone for presumed opioid overdose.Patients who received naloxone for known or presumed opioid overdose were formally evaluated one hour later for multiple potential predictor variables. Patients were classified into two groups: those with adverse events within 24 hours and those without. Using classification and regression tree methodology, a decision rule was developed to predict safe discharge.Clinical findings from 573 patients allowed us to develop a clinical prediction rule with a sensitivity of 99% (95% CI = 96% to 100%) and a specificity of 40% (95% CI = 36% to 45%). Patients with presumed opioid overdose can be safely discharged one hour after naloxone administration if they: 1) can mobilize as usual; 2) have oxygen saturation on room air of92%; 3) have a respiratory rate10 breaths/min and20 breaths/min; 4) have a temperature of35.0 degrees C and37.5 degrees C; 5) have a heart rate50 beats/min and100 beats/min; and 6) have a Glasgow Coma Scale score of 15.This prediction rule for safe early discharge of patients with presumed opioid overdose performs well in this derivation set but requires validation followed by confirmation of safe implementation.

Objective: To determine whether naloxone administered IV to out-of-hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (SQ). Methods: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out-of-hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate ≥10 breaths/min, and durations of bag-valve-mask ventilation. Subjects received either naloxone 0.4 mg IV (n= 74) or naloxone 0.8 mg SQ (n= 122), for respiratory depression of

Dr. Eisenberg is at the University of Washing- ton Medical Center, Seattle, WA, Emergency Medicine Service, and King County Erner- gency Medical Services. Seattle, WA, Center for Evaluation of Emergency Medical Ser- vices. Received: June 12, 1996; accepted: June 20, 1996. Address for correspondence and reprints: Mickey