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Background— Coronary CT angiography (CCTA) is an excellent tool for noninvasive assessment of coronary arteries in low- to intermediate-risk individuals. However, the accuracy of CCTA heavily depends on image quality. Our objective was to develop and validate a tool to predict pre-CCTA risk of obtaining an uninterpretable result in symptomatic patients. Methods and Results— Among 8585 symptomatic patients, we identified variables independently associated with the presence of at least 1 uninterpretable major coronary segment to create the uninterpretable risk score (URS). This risk score was developed using both clinical variables and patient variables acquired at the time the CCTA was performed (heart rate and coronary calcium). The URS was then prospectively validated among an additional 915 symptomatic patients. The URS was predictive of uninterpretable results in both the development and the validation cohorts. For every 4-point increase in the URS (range, 0 to 12), the rate of at least 1 uninterpretable coronary segment per 100 CCTA studies increased ≈1.5 fold. Increased heart rate and coronary artery calcium score were predictive of uninterpretable CCTA study results. Uninterpretable results were associated with 3-month outcomes in the development cohort. Conclusions— The URS can categorize patients who are likely to have at least 1 uninterpretable major coronary segment on CCTA. This may aid in appropriate patient selection for CCTA and avoiding radiation exposure in those likely to have an uninterpretable study. Clinical Trial Registration— URL: http:///www.clinicaltrials.gov . Unique identifier: NCT00640068.

The effective delivery and continued advancement of health care is critically dependent on the relationship between physicians and industry. The private sector accounts for 60% of the funding for clinical research and more than 50% of the funding sources for physician education. The nature of the physician-industry relationship and the role of the physician as a gatekeeper for health care make this association vulnerable to abuse if certain safeguards are not observed. This article will review the current federal guidelines that affect the physician-industry relationship and highlight several illustrative cases to show how the potential for abuse can subvert this relationship. The recommendations and "safe harbors" that have been designed to guide business relationships in health care are discussed.

This study examined one-year violence outcomes among non-injured patients treated in the Emergency Department (ED) for cocaine-related chest pain. An urban Level I ED required patients with chest pain (age 60 and younger) provide a urine sample for cocaine testing. Cocaine-positive consenting patients (n=219) were interviewed in the ED; 80% completed follow-up interviews over 12-months (n=174; 59% male, 79% African-American, mean age = 38.8, standard deviation 9.06; range = 19 to 60). Baseline rates of past year violent victimization and perpetration history were: 38% and 30%, respectively. During the12-month follow-up, rates of victimization and perpetration outcomes were 35% and 30%, respectively. Predictors of violence outcomes (either victimization or perpetration) in the year post-ED visit based on characteristics measured at baseline or during the follow-up period (i.e., gender, age, psychological distress, binge drinking days, cocaine use days, marijuana use days, substance abuse/dependence diagnosis, victimization/perpetration history). Victimization during the follow-up was related to younger age, more frequent binge drinking and marijuana use at baseline, and victimization history, and to substance abuse/dependence, more frequent binge drinking, and psychiatric distress at follow-up. Specifically, participants who reported victimization at baseline were approximately 3 times more likely to report victimization at 12-month follow-up. Perpetration during the follow-up was related to younger age and more frequent binge drinking at baseline, and to substance abuse/dependence, more frequent binge drinking, and psychiatric distress at follow-up. Overall, no significant gender differences were observed in violence; however, women were more likely than men to report injury during the most severe partner violence incident. Violence is a common problem among patients presenting to an inner city ED for cocaine-related chest pain, with younger age and frequency of binge drinking being a consistent marker of continued violence involvement. Intervention approaches to link these not-in-treatment cocaine users to services and reduce cocaine use must take into account concomitant alcohol misuse and violence.

Objectives: Continuous or bilevel positive airway pressure ventilation, called noninvasive ventilation (NIV), is a controversial therapy for acute decompensated heart failure (ADHF). While NIV is considered safe and effective in patients with chronic obstructive pulmonary disease (COPD), clinical trial data that have addressed safety in ADHF patients are limited, with some suggestion of increased mortality. The objective of this study was to assess mortality outcomes associated with NIV and to determine if a failed trial of NIV followed by endotracheal intubation (ETI) (NIV failure) is associated with worse outcomes, compared to immediate ETI. Methods: This was a retrospective analysis of the Acute Decompensated Heart Failure National Registry (ADHERE), which enrolls patients with treatment for, or with a primary discharge diagnosis of, ADHF. The authors compared characteristics and outcomes in four groups: no ventilation, NIV success, NIV failure, and ETI. One-way analysis of variance or Wilcoxon testing was performed for continuous data, and chi-square tests were used for categorical data. In addition, multivariable logistic regression was used to adjust mortality comparisons for risk factors. Results: Entry criteria were met by 37,372 patients, of which 2,430 had ventilation assistance. Of the ventilation group, 1,688 (69.5%) were deemed NIV success, 72 (3.0%) were NIV failures, and 670 (27.6%) required ETI. The NIV failure group had the lowest O2 saturation (SaO2) (84 ± 16%), compared to either NIV success (89.6 ± 10%) or ETI (88 ± 13%; p = 0.017). ETI patients were more likely to receive vasoactive medications (p 0.05); other than that the NIV failure group more often received vasodilators (68.1% vs. 54.3%; p = 0.026). In-hospital mortality was 7.9% with NIV, 13.9% with NIV failure, and 15.4% with ETI. After risk adjustment, the mortality odds ratio for NIV failure versus ETI increased to 1.43, although this endpoint was not statistically significant. Conclusions: In this analysis of ADHF patients receiving NIV to date, patients placed on NIV for ADHF fared better than patients requiring immediate ETI. Patients who failed NIV and required ETI still experienced lower mortality than those initially placed on ETI. Thus, while the ETI group may be more severely ill, starting therapy with NIV instead of immediate ETI will likely not harm the patient. When ETI is required, mortality and length of stay may be adversely affected. Since a successful trial of NIV is associated with improved outcomes in patients with ADHF, application of this therapy may be a reasonable treatment option. ACADEMIC EMERGENCY MEDICINE 2008; 15:355‐362 a 2008 by the Society for Academic Emergency Medicine

Perceptions of cardiovascular risk among adolescents have not been studied recently. The rise in unattended risk factors and the obesity pandemic have created calculable cardiovascular disease risk in the adolescent population.We sought to assess the awareness, level of knowledge, and perception of cardiovascular disease in an adolescent population.We administered a survey designed to collect data on demographics, beliefs regarding risk factor importance, perceived future risk and other knowledge-based assessment questions about cardiovascular disease.Students, n=873, (45.4% male, mean age 15.6 years) in grades 9-12, from four Michigan high schools completed the survey unassisted. Accidents were rated as the greatest perceived lifetime health risk (39.1%). A minority (16.6%) of respondents selected cardiovascular disease as the greatest lifetime risk placing it behind accidents and cancer. When asked to identify the greatest cause of death for each sex, 42.3% of respondents correctly recognized cardiovascular disease for men and 14.0% correctly recognized cardiovascular disease for women in the United States, P0.0001. Forty percent of respondents incorrectly chose a substance abuse/use behavior, other than cigarettes, as the most important cardiovascular disease risk behavior.Our findings suggest that adolescents lack knowledge regarding the risk of cardiovascular disease and do not perceive themselves at risk for cardiovascular disease. These data will be useful in designing future preventive strategies and interventions aimed at this target population.

Objective To identify factors that define a low-risk cohort of patients with acute decompensated heart failure who are suitable for management in an observation unit. Methods Prospective convenience sample of 538 patients who presented to an ED with a diagnosis of congestive heart failure. Observation unit appropriate was defined as a length of stay less than 24 hours and no adverse events (myocardial infarction, death, arrhythmia, or rehospitalization) during the 30-day follow-up period. Results Study criteria were met by 499 patients (mean age, 61 ± 15 years), and 234 (47%) were women. Of these, 133 (27%) met the criteria for observation unit appropriateness. Independent predictors were systolic blood pressure of greater than 160 (odds ratio, 1.8; 95% confidence interval, 1.15-2.7) and normal troponin I (odds ratio, 14.7; 95% confidence interval, 1.9-105). Conclusion Initial blood pressure and troponin I can help identify patients with congestive heart failure at low risk for prolonged hospitalization and adverse events and who are reasonable candidates for observation unit management.

Cocaine-mediated erythrocytosis is one of several effects that cocaine may have on hematologic indices; however, the precise mechanism by which cocaine induces peripheral erythrocytosis is not fully understood. The objective of this study was to examine the contribution of the bone marrow to cocaine-mediated erythrocytosis.Differences in mean hemoglobin concentration, hematocrit, and reticulocyte counts were measured in consecutive cocaine-exposed and cocaine-unexposed patients who presented to the emergency department (ED) with chest pain. Acute cocaine exposure (3 hours) was confirmed by history and toxicologic analysis of the urine on all patients. Means were compared using independent-samples t-test and covariates were examined using multiple regression.Seventy-nine patients met enrollment criteria. Hemoglobin and hematocrit levels were significantly elevated in the cocaine-using subjects (13.5/39.8) compared with controls (12.6/37.7; p0.02). However, no corresponding elevation in reticulocyte count (p = 0.2) was observed. Multivariate logistic regression revealed that male chest pain patients were significantly more likely to be exposed to cocaine (OR 5.15 [95% CI = 1.77 to 15.3]) than females (p = 0.001), and all relative increases in hemoglobin concentration in the cocaine-exposed group were attributable to gender. Cocaine exposure was not significantly associated with reticulocyte count. Multivariate linear regression revealed that of demographic, medical, and substance use covariates, only a history of diabetes mellitus was significantly associated with an elevated reticulocyte count (p = 0.009).Acute cocaine exposure is not associated with erythrocytosis in younger ED patients with chest pain. The lack of an elevated reticulocyte count suggests that bone marrow does not contribute to any transient erythrocytosis that may occur.

background Retrospective studies of patients with cocaine-associated chest pain suggest that a strategy of discharging patients from the emergency department after a 12-hour observation period if they do not have evidence of ischemia should be associated with a very low rate of complications. methods We prospectively evaluated the safety of a 9-to-12-hour observation period in patients with cocaine-associated chest pain who were at low-to-intermediate risk of cardiovascular events. Consecutive patients who reported or tested positive for cocaine use and who received protocol-driven care in a chest-pain observation unit were included. Patients who had normal levels of troponin I, without new ischemic changes on electrocardiography, and who had no cardiovascular complications (dysrhythmias, acute myocardial infarction, or recurrent symptoms) during the 9-to-12-hour observation period were discharged from the unit. The main outcome was death from cardiovascular causes at 30 days. results Three hundred forty-four patients with cocaine-associated chest pain were evaluated. Forty-two of these patients (12 percent) were directly admitted to the hospital. The study cohort comprised the remaining 302 patients. During the 30-day follow-up period, none of the patients died of a cardiovascular event (0 percent; 95 percent confidence interval, 0 to 0.99), and only 4 of the 256 patients for whom detailed follow-up data were available had a nonfatal myocardial infarction (1.6 percent; 95 percent confidence interval, 0.1 to 3.1). All four nonfatal myocardial infarctions occurred in patients who continued to use cocaine. conclusions Patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9-to-12-hour period in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge.

Background Over a 12-month period, adolescent heart-screening programs were performed for identifying at-risk adolescents for sudden cardiac death (SCD) in our community. Novel to our study, all adolescents received an abbreviated, ultraportable echocardiography (UPE). In this report, we describe the use of UPE in this screening program. Methods and Results Four hundred thirty-two adolescents underwent cardiac screening with medical history questionnaire, physical examination, 12-lead electrocardiogram (ECG), and an abbreviated transthoracic echocardiographic examination. There were 11 abnormalities identified with uncertain/varying clinical risk significance. In this population, 75 adolescents had a murmur or high ECG voltage, of which only three had subsequent structural abnormalities on echocardiography that may pose risk. Conversely, UPE discovered four adolescents who had a cardiovascular structural abnormality that was not signaled by the 12-lead ECG, medical history questionnaire, and/or physical examination. Conclusions The utilization of ultraportable, handheld echocardiography is feasible in large-scale adolescent cardiovascular screening programs. UPE appears to be useful for finding additional structural abnormalities and for risk-stratifying abnormalities of uncertain potential of adolescents’ sudden death.

Objective: Prior studies addressing the incidence of acute myocardial infarction (AMI) in pa- tients with cocaine-associated chest pain have found divergent results. Previous prospective studies, which found approximately a 6% incidence of AMI, have been criticized for selection bias. This study sought to determine the rate of AMI in patients with cocaine- associated chest pain. Methods: All patients seen in an urban university-affiliated hospital between July 1996 and February 1998 were identified by ICD-9 medical records search for cocaine use and chest pain/ acute coronary syndromes. In this system, all faculty admit all patients with cocaine-associated chest pain for at least 23-hour observation periods. Data col- lected included demographics, medical and cocaine use history, presenting characteristics, hospital course, cardiovascular complications, and diagnostic tests using a 119-item closed-question data instru- ment with high interrater reliability. The main out- come measure was AMI according to World Health Organization (WHO) criteria. Results: There were 250 patients identified with a mean age of 33.5 6 8.5 years; 77% were male; 84% were African American. Of 196 patients tested, 185 had cocaine or cocaine metabolites in the urine (94%). The incidence of car- diac risk factors were: hypercholesterolemia, 8%; di- abetes, 6%; family history, 34%; hypertension, 26%; tobacco use, 77%; prior MI, 6%; and prior chest pain, 40%. Seventy-seven percent admitted to cocaine use in the preceding 24 hours: crack, 85%; IV, 2%; nasal, 6%. Twenty-five patients (10%) had electrocardio- graphic evidence of ischemia. A total of 15 patients experienced an AMI (6%; 95% CI = 4.1% to 8.9%) us- ing WHO criteria. Complications were infrequent: bradydysrrhythmias, 0.4%; congestive heart failure, 0.4%; supraventricular tachycardia, 1.2%; sustained ventricular tachycardia, 0.8%. Conclusion: The inci- dence of AMI was 6% in patients with cocaine-asso- ciated chest pain. This result is identical to that

Objective. Rapid onset of sleep, brief duration of action, and ease of administration are properties that make rectal methohexital (MXT) an attractive choice for sedating stable pediatric emergency department (ED) patients for computed tomography (CT) imaging. Methodology. One hundred stable patients between 3 and 60 months of age who presented to any of 3 participating EDs and required sedation to undergo CT scanning were given 25 mg/kg of rectal MXT ∼15 minutes before their imaging. Vital signs and oxygen saturation were recorded at regular intervals. Data collected included indication for CT imaging, time to achieve sleep, time to reach discharge criteria, adequacy of sedation, adverse effects, and parental satisfaction. Results. Ninety-five percent of the patients were adequately sedated with rectal MXT. It took an average of 8 minutes to achieve full sedation and the duration of action averaged 79.3 minutes. Ten percent had transient side effects, but all recovered completely. None required intubation. Parental satisfaction was 90%. Conclusion. Rectal MXT compares favorably to other methods of nonintravenous sedation for CT scanning of stable pediatric ED patients in terms of rapidity of onset and reliability but does cause a significant amount of transient respiratory depression. Its use requires careful monitoring of oxygen saturation and should be used only in a setting where physicians skilled in airway management are present. If these requirements are met, it may be a good choice for the relatively noninvasive sedation of pediatric ED patients undergoing painless but anxiety-provoking procedures. methohexital, pediatric procedure sedation, rectal administration, computerized tomography imaging.

The medical community first took notice of the current conflict of interest enigma in the 1980s. 1,2 Since then, numerous studies, editorials, and policy statements have attempted to elucidate the magnitude and diverse nature of these conflicts involving physicians, physician researchers, and their affiliated institutions. 2,14,24,25,39,40,43,47,52,78 Although conflicts of interest in medicine are ubiquitous, much confusion remains over how to comprehend and address these problems appropriately, because conflicts may merely represent a set of conditions, and not necessarily an explicit behavior. 83 This seemingly subtle difference is of immense importance when considering that the public expects physicians to act justly, professionally, and in society's best interest. Therefore, even the mere appearance of a conflict of interest can undermine the credibility of physicians, and therefore propagate public mistrust. 22,77 The purpose of this article is to further enhance the understanding of conflicts of interest as they apply to emergency physicians, using three distinct paradigms: the industry, clinical practice, and academic models. This is not intended as a comprehensive review but should serve as a resource for emergency physicians when confronting day-to-day ethical conflicts.

Appropriate concerns about cost and unequal access to healthcare have resulted in the creation of powerful managed networks seeking to share the risks of high healthcare costs among plans, providers, and patients. Much to their credit, these managed networks have slowed the rise in healthcare spending by as much as 44% in markets with high HMO penetration. However, whether these savings will materially improve access and quality remains to be seen.

As the pool of available health care resources continues to evaporate, emergency physicians will be increasingly required to guard against the provision of expensive, unnecessary, and marginally beneficial care. This article proposes that emergency physicians embrace the ethic of prudent resource stewardship to ensure the continued availability of emergency services to all who need them. When making resource allocation decisions, emergency physicians must consider the likelihood, magnitude, and duration of benefits to patients, the urgency of the condition, and the cost and burdens of treatment to patients, payers, and society. These considerations go beyond professional duties to individual patients and suggest that ignoring the burdens of emergency department microallocation decisions is socially and morally irresponsible.

An 86-year-old man arrived by ambulance at the emergency department (ED) at 7:15 P.M. with shortness of breath, wheezing, and sweating. The history obtained of his present illness was brief due to the patient’s extreme dyspnea. He had missed his dialysis appointment the previous day, and he complained of worsening shortness of breath that morning. En route he received nebulized albuterol and was on 100% O2 by nonrebreather mask. The patient had suffered a myocardial infarction approximately 7 years previously. He had also undergone two cardiac catheterizations documenting extensive coronary artery disease (CAD), resulting in angioplasty with subsequent stent placement. In addition, he had a history of congestive heart failure (CHF) and hypertension that precipitated end-stage renal failure requiring hemodialysis. He also had chronic obstructive pulmonary disease (COPD) and was on home O2 at 2 l/min. His medications were as follows: enalapril 40 mg/day, clonidine 0.1 mg t.i.d., isosorbide dinatrate 25 mg/day, atenolol 25 mg/day, salmeterol 2 puffs b.i.d., fluticasone 2 puffs b.i.d., albuterol p.r.n., lansoprazole 15 mg/day, calcium acetate 665 mg t.i.d., and Nephrocaps 1/day.

‘With the absence of clearly defined management guidelines, up to 15% of patients who sustaincocaine-associated myocardial infarction are inadvertently released prior to the discovery of acute myocardial infarction.’

Objectives: The authors surveyed the membership of the Society for Academic Emergency Medicine (SAEM) about their associations with industry and predictors of those associations. Methods: A national Web-based survey inviting faculty from the active member list of SAEM was conducted. Follow-up requests for participation were sent weekly for 3 weeks. Information was collected on respondents’ personal and practice characteristics, industry interactions, and personal opinions regarding these interactions. Raw response rates were reported and a logistic regression was used to generate descriptive statistics. Results: Responses were received from 430 members, representing 14% of the 3,183 active members. Respondents were 83% male and 86% white, with 96% holding an MD degree (24% with an additional postdoctoral degree). Most were at the assistant (37%) or associate (25%) professor rank, with 51% holding at least one leadership position. Most respondents (82%) reported some type of industry interaction, most commonly the acceptance of food or beverages (67%). Respondents at the associate professor rank or higher were more likely to receive payments from industry (51% vs. 22%, odds ratio [OR] = 3.7). Conclusions: This survey suggests that interactions between industry and academic EM faculty are common and increase with academic rank, but not with years in practice or leadership influence. The number and type of interactions are consistent with those reported by a national sampling of other physician specialties. ACADEMIC EMERGENCY MEDICINE 2008; 15:819–824 a 2008 by the Society for Academic Emergency

Illicit stimulant drug use may have a profound clinical impact in acute decompensated heart failure (ADHF). The chronic use of cocaine and methamphetamine may lead to overt cardiomyopathy and ADHF. The Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM) collected data on patients presenting to emergency departments with ADHF at 83 geographically dispersed hospitals in the United States. This registry was queried to determine the rate of self-reported illicit drug use in emergency department patients presenting with ADHF and compare these patients with those without illicit drug use. The registry enrolled 11,258 patients with ADHF with drug use data from January 2004 to March 2006. Of these patients, 594 (5.3%) self-reported current or past stimulant drug use. Compared with nonusers, these patients were more likely to be younger (median age 49.7 vs 76.1 years), to be African American (odds ratio 11.9, 95% confidence interval 9.8 to 14.4), and to have left ventricular ejection fractions

Chest pain is the most common complaint among cocaine users who present to the emergency department (ED) seeking care, and many hospital resources are applied to stratify cocaine users in regard to future cardiac morbidity and mortality. Little is known about the longitudinal cardiac and noncardiac medical outcomes of cocaine users who have been stratified to an ED observation period after their ED visit. We examine 1-year cardiac outcomes in a low- to intermediate-risk sample of patients with cocaine-associated chest pain in an urban ED, as well as examine ED recidivism at 1 year for cardiac and noncardiac complaints.Prospective consecutive cohort study of patients (18 to 60 years) who presented to an urban Level I ED with cocaine-associated chest pain and were risk stratified to low to intermediate cardiac risk. Exclusion criteria were ECG suggestive of acute myocardial infarction, increased serum cardiac markers, history of acute myocardial infarction or coronary artery bypass graft, hemodynamic instability, or unstable angina. Baseline interviews using validated measures of health functioning and substance use were conducted during chest pain observation unit stay and at 3, 6, and 12 months. ED utilization during the study year was abstracted from the medical chart. Zero-inflated Poisson regression analyses were conducted to predict recurrent ED visits.Two hundred nineteen participants (73%) were enrolled, 65% returned to the ED post-index visit, and 23% returned for chest pain; of these, 66% had a positive cocaine urine screening result. No patient had an acute myocardial infarction within the 1-year follow-up period. Patients with continued cocaine use were more likely to have a recurrent ED visit (P.001), but these repeated visits were most often related to musculoskeletal pain (21%) and injury (30%), rather than potential cardiac complaints.Patients with cocaine-associated chest pain who have low to intermediate cardiac risk and complete a chest pain observation unit protocol have a less than 1% rate of myocardial infarction in the subsequent 12 months.

Objectives: It has been reported that the mortality risk for heart failure differs between men and women. It has been postulated that this is due to differences in comorbid features. Variation in risk profiles by gender may limit the performance of stratification algorithms available for heart failure in women. This analysis examined the ability of a published risk stratification model to predict outcomes in women. Methods: The Acute Decompensated Heart Failure National Registry Emergency Module (ADHEREEM) database was used. Characteristics, treatments, and outcomes for men and women were compared. The ADHERE registry classification and regression tree (CART) analysis was used for the risk stratification evaluation. Results: Of 10,984 ADHERE-EM patients, 5,736 (52.2%) were women. In-hospital mortality was similar between men and women (p = 0.727). Significant differences (p < 0.0002) were noted by gender in all three variables in the CART model (blood urea nitrogen [BUN] ‡ 43 mg ⁄dL, systolic blood pressure < 115 mm Hg, and serum creatinine ‡ 2.75 mg ⁄dL). However, the CART model effectively stratified both genders into distinct risk groups with no significant difference in mortality by gender within stratified groups. Conclusions: The ADHERE Registry CART tool is effective at predicting risk in ED patients, regardless of gender. ACADEMIC EMERGENCY MEDICINE 2008; 15:151‐158 a 2008 by the Society for Academic Emergency

This study examines a consecutive cohort of patients (n = 219) presenting to an urban Emergency Department (ED) for cocaine-related chest pain (June 2002 to February 2005). Patients were interviewed regarding violence, substance use, and psychosocial factors. Significant markers of violence were increases in: past-year medical service use, binge drinking, marijuana use, cocaine diagnosis, but not cocaine use days. Rates and correlates of violence differed by relationship type (intimate partner, nonpartner) and role context (victimization, perpetration). Understanding these correlates has public health implications, both for preventing future violence and its associated ED service utilization, and for future interventions in cocaine users presenting to the ED.

Acutely decompensated heart failure (ADHF) is characterized by hemodynamic abnormalities and neurohormonal activation that contribute to heart failure (HF) symptoms, end-organ dysfunction, arrhythmias, and progressive cardiac failure. The management of ADHF in the emergency department (ED) can be simplified and improved by a 2-min bedside assessment that identifies any of four possible hemodynamic profiles on the basis of clinical signs and symptoms. The profiles are based on whether congestion is present or absent (wet or dry) and perfusion is adequate or limited (warm or cold). A wet-warm profile is seen more frequently in the ED than any of the other three profiles (wet-cold, dry-warm, and dry-cold). The four clinically determined profiles have been shown to predict clinical outcomes and may be used to guide initial HF therapy. The goals of treating ADHF are to stabilize the patient, reverse acute hemodynamic abnormalities, rapidly reverse dyspnea and/or hypoxemia caused by pulmonary congestion, and initiate treatments that will decrease disease progression and improve survival. An ideal agent for the wet-warm profile would rapidly reduce pulmonary congestion, produce balanced arterial and venous dilation, promote natriuresis, lack direct positive inotropic effects, and not cause reflex neuroendocrine activation. Intravenous nesiritide in conjunction with loop diuretics has been found safe and effective as initial treatment for patients with the wet-warm profile. For the wet-cold profile, more intensive therapy and invasive hemodynamic monitoring may prove useful. This review will discuss the rapid clinical determination of hemodynamic profiles in patients presenting to the ED with ADHF and the options for their initial medical management. Case studies representing the wet-warm, wet-cold, dry-warm, and dry-cold profiles will be presented and discussed.

Venous thromboembolism (VTE) is a concerning problem for hospitalized heart failure (HF) patients. Current recommendations are that all hospitalized New York Heart Association Class III or IV HF patients should receive VTE prophylaxis. Our purpose was to describe the rate of use and the characteristics of patients receiving VTE prophylaxis in the Acute Decompensated Heart Failure National Registry (ADHERE).HF hospitalization episodes in ADHERE were analyzed. Patients were excluded from analysis if they were receiving Coumadin or intravenous heparin, had elevated troponin levels, underwent cardiac catheterization or dialysis before or during hospitalization, or were initially admitted to the intensive care unit. VTE prophylaxis was defined as low-molecular-weight or subcutaneous unfractionated heparin administered at any time during hospitalization and intravenous vasoactive therapy was defined as any inotrope, inodilator, or vasodilator. Chi-square, analysis of variance, and Wilcoxon tests were used for univariate and multivariate analyses. Logistic regression was used to evaluate outcomes. A total of 155,073 entries were evaluated, with 71,376 eligible for VTE prophylaxis; 21,847 (31%) received VTE prophylaxis. VTE prophylaxis patients were more often African American (28% versus 21%) or admitted from the emergency department (84% versus 79%), compared with those who did not receive VTE prophylaxis (both P.0001). Medical history and initial presentation characteristics were similar, except edema, which was more likely in VTE prophylaxis patients (71% versus 66%, P.0001). Patients receiving VTE prophylaxis more often received an intravenous vasoactive agent (23% versus 18%), angiotensin-converting enzyme inhibitor (61% versus 54%), or beta-blocker (63% versus 58%) during their hospitalization and were more likely discharged on an angiotensin-converting enzyme inhibitor (53% versus 49%) or beta-blocker (57% versus 54%) than non-VTE prophylaxis patients, all P.0001. VTE prophylaxis patients were more often admitted to the intensive care unit (4.8% versus 2.5%, P.0001) and had longer median hospital stays (4.2 versus 3.8 days, P.0001). Mortality was similar between cohorts (3.0% versus 2.9%, P = .69).Despite recommendations that all hospitalized New York Heart Association III and IV CHF patients receive venous thromboembolic disease prophylaxis, less than one third of eligible patients receive this guideline recommended therapy.

Emergency department (ED) physicians are critical in the accurate diagnosis, efficient management, and treatment of patients with ST-segment elevation myocardial infarction. The initial reperfusion strategy involves the choice between mechanical reperfusion using primary percutaneous coronary intervention and pharmacologic treatment with fibrinolytics. The benefits of these approaches are time dependent, and practices vary according to institutional resources and local guidelines. Nevertheless, the need for early intervention and the use of certain therapies are well recognized. Therefore, ED physicians must be aware of all treatment options available, including the use of adjunctive therapies. Initial treatment should include beta-blockers, aspirin (or clopidogrel if aspirin is contraindicated), nitroglycerin, and analgesia, regardless of reperfusion strategy. Clopidogrel is now approved as an adjunctive therapy for patients undergoing fibrinolysis as their reperfusion therapy. Both unfractionated heparin and low-molecular-weight heparin are feasible adjunctives in patients with ST-segment elevation myocardial infarction undergoing reperfusion therapy. In addition, multiple new antithrombin agents are being investigated. The choice adjunctive treatments should be based on specific patient populations and on the initial reperfusion strategy.

Objective To examine rates and correlates of self-reported perpetrated violence among teens presenting to an urban emergency department. Study design Cross-sectional study of a consecutive sample of youth (12-17 years) presenting to an urban emergency department. The youth were surveyed about demographics, community violence exposure, parental monitoring, substance use, weapon carriage, group fighting, and aggression (past 12 months). Bivariate and multivariate analyses were performed to identify correlates of the severity of the violence (none, moderate, or severe) perpetrated in the past year. Results A total of 115 youth were surveyed (males, 47%; response rate, 85%). The sample group was 51% African American. A total of 77% of the youth reported that they perpetrated violence in the past year, with 37% reporting severe violence (use of a weapon, group fighting, causing an injury requiring medical care). All patients who self-reported perpetrating severe violence in the past year were discharged home from the emergency department. The diagnosis made in the emergency department (illness versus injury) was not associated with the violence perpetrated in the past year. Sex was not a significant predictor of severe perpetrated violence. Conclusions Youth presenting to urban emergency departments report high rates of perpetrating violence in the past year that, on the basis of other studies, is likely to continue. These results suggest that future emergency department-based violence prevention efforts should consider universal screening of adolescents.

Objectives: This report examines the sociodemographic and substance use characteristics, co-occurring psychological status, substance abuse consequences, and prior experiences with substance abuse treatment among patients with cocaine-associated chest pain presenting to an emergency department chest pain observation unit. Methods: This was a consecutive cohort of patients in the emergency department chest pain observation unit aged 18–60 years with low to moderate risk for acute coronary syndrome and recent cocaine use. Responses on standardized and validated instruments were used to examine demographic and clinical characteristics of the sample and to compare patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for past three-month substance abuse or substance dependence with patients who did not. Results: Of 145 eligible patients identified between June 1, 2002, and February 29, 2004, 86% met criteria for a lifetime DSM-IV substance use disorder and 50% met past three-month criteria. Approximately one half of the total sample reported substantial symptoms of depression. Substance use frequency and consequences, depression, and psychological distress were significantly more severe among those with past three-month substance use diagnoses; however, most sociodemographic characteristics were not associated with substance use diagnoses. Interest in treatment services and treatment history was also significantly associated with the presence of a substance use disorder diagnosis. Conclusions: Findings regarding diversity in alcohol and drug involvement, current level of psychological functioning, depressive symptomatology, and interest in treatment services provide useful information for designing emergency department–based interventions for this population. Key words: cocaine; chest pain; emergency department; demography; substance-related disorders; behavioral symptoms. ACADEMIC EMERGENCY MEDICINE 2005; 12:329–337.

Study objective To determine whether an emergency department (ED)–based laptop computer intervention reduces the normative age-related increase in alcohol misuse compared with standard of care. Methods This was a randomized controlled trial conducted from October 11, 1999, to April 14, 2001, in a community teaching hospital and university medical center. Subjects were aged 14 to 18 years and with a minor injury. Controls and intervention participants completed a computer-based questionnaire. Intervention participants also completed a laptop-based interactive computer program to affect alcohol misuse. Main outcome measures were Alcohol Misuse Index (Amidx) and binge-drinking episodes. Follow-up occurred by telephone at 3 and 12 months. Analysis included repeated-measures analysis of variance (α=0.05; power 0.80; effect size 0.10). Results Three hundred twenty-nine participants were randomized to the intervention group, and 326 participants were randomized to the control group. Two hundred ninety-five (89.7%) intervention subjects and 285 (87.4%) control subjects completed 3- and 12-month follow-ups. For intervention and control groups, respectively, mean age was 16.0 and 15.9 years and men composed 66.8% and 66.3% of the groups; Amidx scores were 2.2 and 2.0; binge-drinking episodes were 1.2 and 1.0. Outcomes for intervention and control, respectively, were Amidx (3 months) 1.5 and 1.4; Amidx (12 months) 1.8 and 2.1; binge drinking (3 months) 0.9 and 0.8; and binge drinking (12 months) 1.4 and 1.2. Overall, there were no significant effects (effect size 0.04). No detrimental effects were noted. Subgroup analysis suggested that the intervention may have an effect among subjects with experience drinking and driving (5% of the sample). Conclusion The intervention was not effective in decreasing alcohol misuse among the study population. Further research will be required to determine effectiveness among the subgroup of adolescent minor injury patients who have experience drinking and driving.

Numerous factors have been implicated in the pathogenesis of cocaine associated myocardial infarction (CAMI). However, the relative contributions each of these mechanisms provide to the pathogenesis of CAMI have not been well defined. We hypothesized that significant angiographic differences exist between CAMI patients vs thrombotic AMI patients (TAMI) and normal controls.The TIMI Flow Grade, corrected TIMI Frame Count (CTFC), TIMI Myocardial Perfusion Grade (TMPG), presence of triple-vessel disease, stenosis severity, and presence of angiographically apparent thrombus were compared in patients who sustained CAMI to TAMI patients and normal controls.2495 angiograms were analyzed (CAMI = 57, TAMI = 2403, Controls = 35). Impairment in both epicardial and microvascular flow in patients with CAMI was intermediate between TAMI and controls. Compared to TAMI patients, CAMI patients were less likely to have 3 vessel disease (8.9% vs. 19.1%; p0.05), epicardial stenosis was less severe (14.9+/-30.2 vs. 72.6+/-18.6; p0.0001), less thrombus was present (6.5% vs. 33.1%; p0.001) and TIMI grade 3 flow was observed more frequently (76% vs. 59%). Normal TMPG 3 perfusion was significantly impaired in both CAMI and TAMI patients when compared to controls without AMI (TMPG 3 was 40% and 26.6% vs. 100% respectively; p0.001 for both). The majority of patients in both AMI groups had diminished or absent tissue level perfusion (TMPG 0 flow, CAMI 53.9 vs. TAMI 56.8%).Both epicardial and microvascular flow is impaired in CAMI. While epicardial flow among CAMI patients is slightly better than TAMI patients, the incidence of little or severely impaired tissue level perfusion is nearly identical.

To identify the frequency of current or lifetime history of alcohol and/or other drug (AOD) use among the full range (admitted and discharged) of injured bicyclists and pedestrians involved in motor vehicle crashes.In a prospective study of non-occupant motor vehicle crash (NOMVC) victimsor=18 years over a 29-month period, blood was obtained for alcohol and drug testing. Current alcohol abuse/alcohol dependence (AA/AD) or drug abuse/drug dependence (DA/DD) was based on the Diagnostic Interview Survey.In all, there were 108 NOMVC victims. Eleven per cent were alcohol (+), 7% drug (+), and 3% both. Sixteen per cent were AA/AD (+), 2.7% DA/DD (+), and 1.4% both.A substantial portion of patients with NOMVC injuries tested AOD (+) and had a current or lifetime substance abuse (AA/AD; DA/DD) diagnosis.

Despite the increasing recognition of the problem of domestic violence (DV), it has not been studied in surgical populations.Eligible patients underwent screening for a recent history of DV and alcohol abuse (AA). Other demographic, health, and injury-related data were also collected.Of 127 subjects entered into the study, 18% screened positive for DV and 21% screened positive for AA. Of those screening positive for DV, 65% screened positive for AA compared with 12% of those screening negative for DV (p0.001.) Screening for DV was recommended by a vast majority of subjects, with only 6% of subjects responding that it was not appropriate.Both DV and AA have a high prevalence among female trauma patients admitted to trauma centers. Nearly all subjects recommended screening for DV. Screening for DV should be incorporated into the routine care of female trauma patients.

Objective. To compare the additive effect of a helium–oxygen mixture (Heliox) or racemic epinephrine (RE) on croup scores (CSs) in children with moderate to severe croup treated with humidified oxygen and steroids. Design. A prospective, randomized, double-blind trial. Setting. Emergency department and pediatric intensive care unit of an urban level I trauma center. Participants. Randomly assigned, consecutive children ages 6 months to 3 years presenting with moderate to severe croup (CS: ≥5). Interventions. After cool humidified oxygen and 0.6 mg/kg of intramuscular dexamethasone, patients were randomized to receive either Heliox or RE. Vital signs, oxygen saturation, and CSs were recorded at regular intervals. Outcome/Analysis. Reductions in CSs were compared using repeated-measures analysis of variance. Results. Thirty-three patients were enrolled. Three were excluded because of protocol violations, and 1 was excluded because of lack of documentation, leaving 29 patients for final analysis. The average age was 24.2 months, 20 were male (68.8%). Both Heliox and RE were associated with improvement in CSs over time. There were no significant differences in mean CS, oxygen saturation, respiratory rate, or heart rate between groups at baseline or at the end of the treatment period. Conclusion. In patients with moderate to severe croup, the administration of Heliox resulted in similar improvements in CS compared with patients given RE.

Objective To describe the clinical characteristics of a combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department (ED) patients. Methods This was a prospective, observational trial, conducted in the ED of an urban level II trauma center. Patients > or = 18 years of age requiring procedural sedation and analgesia were eligible, and enrolled patients received 0.07 mg/kg of intravenous midazolam followed by 2 mg/kg of intravenous ketamine. Vital signs were recorded at regular intervals. The adequacy of sedation, adverse effects, patient satisfaction, and time to reach discharge alertness were determined. Descriptive statistics were calculated using statistical analysis software. Results Seventy-seven patients were enrolled. Three were excluded due to protocol violations, three due to lack of documentation, and one due to subcutaneous infiltration of ketamine, leaving 70 patients for analysis. The average age was 31 years, and 41 (59%) were female. Indications for procedural sedation and analgesia included abscess incision and drainage (66%), fracture/joint reduction (26%), and other (8%). The mean dose of midazolam was 5.6 +/- 1.4 mg and the mean dose of ketamine was 159 +/- 42 mg. The mean time to achieve discharge criteria was 64 +/- 24 minutes. Five patients experienced mild emergence reactions, but there were no episodes of hallucinations, delirium, or other serious emergence reactions. Eighteen (25%) patients recalled dreaming while sedated; twelve (17%) were described as pleasant, two (3%) unpleasant, three (4%) both pleasant and unpleasant, and one (1%) neither pleasant nor unpleasant. There were four (6%) cases of respiratory compromise, two (3%) episodes of emesis, and one (1%) case of myoclonia. All of these were transient and did not result in a change in the patient's disposition. Only one (1%) patient indicated that she was not satisfied with the sedation regimen. Conclusions The combination of midazolam and ketamine provides effective procedural sedation and analgesia in adult ED patients, and appears to be safe.

Study objective: Alcohol, the most commonly used substance among adolescents, is frequently associated with injury. Little is known regarding the drinking characteristics of injured adolescents. Such data are critical for developing emergency department interventions to decrease alcohol-related injury among adolescents. We sought to describe the drinking characteristics of injured adolescents and to describe the relationship of injury severity and mechanisms with drinking characteristics. Methods: This study was a prospective cohort study performed in a university hospital (sampled May 1, 1995, to July 15, 1995) and a large urban teaching hospital (sampled May 1, 1996, to August 1, 1996). The participants were aged 12 to 20 years, presenting within 6 hours of an injury. We performed a saliva alcohol test and self-administered questionnaire. Age, sex, E-code, injury severity score (ISS), and ED disposition were recorded. An alcohol frequency/quantity index was calculated. Descriptive statistics and 95% confidence intervals were calculated. Results: Two hundred sixty-three patients with a mean age of 17 years and a mean ISS of 2.1 (SD 3.5) were recruited. One hundred fifty-two (50%) were males, and 33 (13%) were admitted. Ten (4%) patients had a positive saliva alcohol test response. On average, within the last year, these adolescents had 1.7 adverse alcohol consequences. Sixty percent drank in unsupervised settings, and 36% reported drinking 5 or more drinks in a row. Conclusion: Alcohol use/misuse is a substantial problem among injured adolescents regardless of severity or mechanism of injury. ED physicians should consider screening/intervention or primary prevention of alcohol problems for all injured adolescents. [Maio RF, Shope JT, Blow FC, Copeland LA, Gregor MA, Brockmann LM, Weber JE, Metrou ME. Adolescent injury in the emergency department: opportunity for alcohol interventions? Ann Emerg Med . March 2000;35:252-257.]

The organisation of the American emergency health care system has changed rapidly during recent years, but it remains very different to the system in the United Kingdom. American emergency departments are organised around an attending physician based service, rather than a consultant led service. As a result, the work of the American emergency physician differs considerably from that of the United Kingdom A&E consultant. The problems associated with working in an attending physician based service include antisocial hours of work, sleep deprivation, decreased job satisfaction, and "burn out," all in the context of a relatively hostile medicolegal climate. Although there appear to be no easy answers to some of these problems, the A&E specialist should be aware of the potential future difficulties for A&E medicine as it develops within the United Kingdom.

We present a case of a 98-yr-old woman with acute urinary retention secondary to a large urethral calculus. This is a unique cause of obstructive uropathy for several reasons. First, urethral calculi are extremely rare in American-born Caucasian females. Second, urethral stones in females are nearly always associated with underlying genitourinary pathology; however, subsequent work up failed to reveal any strictures, diverticula, or related processes that may have predisposed this patient to urethral calculus formation. The epidemiology, pathogenesis, clinical presentation, and emergency management of large urethral calculi are reviewed.

Study objective: To develop criteria that optimize clinical decisionmaking in the use of radiography after isolated knee trauma in adults. Design: A prospective survey of emergency department patients over a 7-month period. Standardized data forms were completed by emergency physicians, residents, and certified physician assistants. Setting: A large suburban community teaching hospital. Participants: Two hundred forty-two patients older than 17 years with isolated knee injuries sustained less than 24 hours previously. Results: We constructed a clinical decision model, calculating sensitivity, specificity, and odds ratios. Twenty-eight patients (11.6%) had fractures, with the patella the most commonly fractured osseous structure. Patients able to walk without limping had not experienced a fracture, nor had patients with twist injuries without effusion. Sensitivity of this model for detecting fracture was 1.0 (99% confidence interval, .97 to 1.0), and specificity was .337 (99% confidence interval, .26 to .42). Conclusion: Clinical decision rules are effective in detecting knee fractures with 100% sensitivity and with sufficient specificity to eliminate 29% of knee radiographs in the ED. These findings require prospective validation. [Weber JE, Jackson RE, Peacock WF, Swor RA, Carley R, Larkin GL: Clinical decision rules discriminate between fractures and nonfractures in acute isolated knee trauma. Ann Emerg Med October 1995;26:429-433.]