Efficacy of inhaled steroids (beclomethasone dipropionate) for treatment of mild to moderately severe asthma in the emergency department: a randomized clinical trial.

STUDY OBJECTIVE: To examine the efficacy of an inhaled steroid, when added to a standard regimen of beta-agonist therapy, in the treatment of patients with mild to moderately severe asthma in the emergency department. METHODS: A convenience sample of adult patients with asthma (FEV1 % predicted 40% to 69%) presenting to the ED was randomly assigned in a double-blind fashion into 2 treatment groups. The first group received 2.5 mg nebulized salbutamol plus 1 mg (4 puffs) of beclomethasone dipropionate (BDP) at baseline, 30 minutes, and at 1, 2, and 4 hours, delivered by a metered-dose inhaler (MDI) attached to a spacer device (Vent-AH-aler, Glaxo). The second group was given the same salbutamol regimen plus MDI placebo through the Vent-AH-aler. The primary endpoint was improvement in FEV1 %predicted at 6 hours. RESULTS: Of 54 patients enrolled, 28 were assigned to the BDP group and 26 to the placebo group. Spirometry improved significantly in both groups over the 6 hours compared with baseline (ANOVA, P <.001). At 6 hours, the mean absolute improvement in FEV1 % predicted for BDP was 18% versus 17% for placebo (95% confidence interval for the absolute difference of 1% [-8% to 10%]). The proportion of patients in the BDP group who were hospitalized was 7% compared with 19% for patients in the placebo group (95% confidence interval for the difference of 12% [-6%, 30%]). CONCLUSION: In this group of patients with mild to moderately severe asthma, 5 mg BDP delivered by MDI during the initial 4 hours of an emergency visit was of no added benefit over standard therapy, as measured by improvement in FEV1 % predicted at 6 hours. However, a trend toward a difference in admission favoring BDP was observed. [Afilalo M, Guttman A, Colacone A, Dankoff J, Tselios C, Stern E, Wolkove N, Kreisman H: Efficacy of inhaled steroids (beclomethasone dipropionate) for treatment of mild to moderately severe asthma in the emergency department: A randomized clinical trial.

Emergency department use and misuse.

We conducted a 14-day survey of the emergency department (ED) at a university tertiary care teaching hospital to examine appropriate and inappropriate use of the ED. The results are based on a convenience sample of 849 patients, selected to represent a 1-week period. Three categories (CAT) of patients were defined. CAT I: patients had a medical condition that could only be assessed in the ED. CAT II: patients had a medical condition that required evaluation either in the ED or elsewhere within 6 hours of triage. CAT III: patients could wait to be evaluated 6 or more hours from time of triage. Patients in CAT II were matched with outpatient facilities (OPF), based on the time of presentation, the presenting complaint, investigative tests, and treatments required. Overall, it was found that 69% of the patients were appropriate users and could have been seen only in the ED. Fifteen percent of the patients were classified as inappropriate users and should have been seen at an OPF. The remaining 15.8% represented "gray zone" cases. An interview conducted on a subset of ambulatory patients revealed the main reasons for choosing to visit the ED were lack of awareness of other facilities, perceived seriousness of condition, trust in the ED staff, or proximity of the ED. It was concluded that misusers represent a small portion of our ED caseload.

The prognostic significance of moderate hyperamylasemia in the evaluation of the emergency department patient.

Hyperamylasemia of greater than five times the upper limit of the normal range (200 IU/L) is highly specific for the diagnosis of pancreatitis, but the meaning of lower values is unclear. The purpose of this study was to evaluate the prognostic significance of amylase values > 200 and < 1000 IU/L. A controlled historical cohort study was conducted to determine whether moderate hyperamylasemia is associated with an increased severity of outcome compared to patients with normal amylase values. Subjects met certain inclusion criteria and had a serum amylase of > 200 and < 1000 IU/L (normal < 200 IU/L). The case group consisted of 44 patients (medium serum amylase = 307.5 IU/L) and resembled the control group of 77 patients (median serum amylase = 117.5 IU/L) with regard to sex distribution and presenting complaint. However, the case group was older, was on more medications, and had a shorter duration of symptoms prior to the ED visit (< 72 h). Analysis of clinically important outcomes revealed that the groups were similar in terms of 6-month mortality, general admission rate, ICU admission rate, and rate of surgical intervention. The proportion of patients who had radiologically or endoscopically documented gastrointestinal pathology was also similar. The results demonstrate that patients with moderate hyperamylasemia (i.e. amylase < 1000 IU/L), notwithstanding the fact that they are older, are on more medications, and have more acute symptomatology, did not have a worse outcome than patients with the same complaints and normal amylases.

Fiberoptic intubation in the emergency department: a case series.

A prospective descriptive study was conducted to evaluate the feasibility of using fiberoptic bronchoscopy to replace blind nasotracheal intubation. The study was performed from November 1989 to August 1991 at a university teaching tertiary care hospital. Intubations were performed by three senior emergency physicians with no prior clinical experience in emergency fiberoptic intubation. Training in fiberoptic intubation was carried out on anesthetized patients, intubation manikins, and cadavers. All patients coming to the emergency department who would have been intubated in the blind nasotracheal manner were eligible for fiberoptic intubation, except for apneic patients and those intubated by residents learning other techniques. An independent observer collected the data. Forty-two patients were entered into the study, 22 males and 20 females, with an average age of 64 years. The success rate was 72% (30/42), with one of the investigators performing most of the intubations (22, 52%). His success rate was 82%. The other two investigators' success rates were 64% and 56%. Most failures were ascribed to coping with secretions. In conclusion, intubation with the fiberoptic bronchoscope can be a useful alternative to blind nasotracheal intubation. Success with this technique is dependent on the airway being free of secretions and blood.