Aminophylline in bradyasystolic cardiac arrest: a randomised placebo-controlled trial.

BACKGROUND: Endogenous adenosine might cause or perpetuate bradyasystole. Our aim was to determine whether aminophylline, an adenosine antagonist, increases the rate of return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest. METHODS: In a double-blind trial, we randomly assigned 971 patients older than 16 years with asystole or pulseless electrical activity at fewer than 60 beats per minute, and who were unresponsive to initial treatment with epinephrine and atropine, to receive intravenous aminophylline (250 mg, and an additional 250 mg if necessary) (n=486) or placebo (n=485). The patients were enrolled between January, 2001 and September, 2003, from 1886 people who had had cardiac arrests. Standard resuscitation measures were used for at least 10 mins after the study drug was administered. Analysis was by intention-to-treat. This trial is registered with the ClinicalTrials.gov registry with the number NCT00312273. FINDINGS: Baseline characteristics and survival predictors were similar in both groups. The median time from the arrival of the advanced life-support paramedic team to study drug administration was 13 min. The proportion of patients who had an ROSC was 24.5% in the aminophylline group and 23.7% in the placebo group (difference 0.8%; 95% CI -4.6% to 6.2%; p=0.778). The proportion of patients with non-sinus tachyarrhythmias after study drug administration was 34.6% in the aminophylline group and 26.2% in the placebo group (p=0.004). Survival to hospital admission and survival to hospital discharge were not significantly different between the groups. A multivariate logistic regression analysis showed no evidence of a significant subgroup or interactive effect from aminophylline. INTERPRETATION: Although aminophylline increases non-sinus tachyarrhythmias, we noted no evidence that it significantly increases the proportion of patients who achieve ROSC after bradyasystolic cardiac arrest.

Attitude of emergency department patients with minor problems to being treated by a nurse practitioner.

INTRODUCTION: It may be appropriate for nurse practitioners (NPs) to provide care for a subset of emergency department (ED) patients with non-urgent problems. Our objective was to determine the attitude of ED patients with minor problems to being treated by an NP. METHODS: Consecutive adults who presented to this tertiary ED on weekdays between 8 am and 4 pm were eligible for the study if they had 1 of the following 18 complaints: minor abrasions or lacerations, minor bites, minor burns, minor extremity trauma, cast check, earache, superficial foreign body, lice or pinworms, morning-after pill request, needlestick injury or body-fluid exposure, prescription refill, puncture wound, sore throat, subconjunctival hemorrhage, suture removal or wound check, tetanus immunization request, toothache, or urinary tract infection (women). Unless pain or a language barrier precluded study involvement, a triage nurse gave each patient a brief survey to be completed prior to physician assessment. RESULTS: Of 728 eligible patients during the study period, 246 (34%) were invited to participate and 213 (87%) were enrolled. The mean age was 34.5 years, and 58% were men. When asked about their willingness to be treated by an NP, 72.5% said "yes" (95% confidence interval [CI], 65.8%-78.4%), 15.5% were "uncertain" (95% CI, 10.8%-21.1%) and 12.1% said "no" (95% CI, 8.0%-17.3%). Of those who said "yes," 21% expected to also see an emergency physician during their ED visit and 67% did not. Willingness to be treated by an NP was independent of age, gender or educational status. CONCLUSIONS: A majority of ED patients with minor problems accepted being treated by an NP, often without additional physician assessment. Several factors, including impact on ED staffing and patient flow, logistics, cost and quality of care should be evaluated before implementing such strategies.

Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.

BACKGROUND: Coronary thrombosis and pulmonary thromboembolism are common causes of cardiac arrest. We assessed whether the administration of tissue plasminogen activator (t-PA) during cardiopulmonary resuscitation would benefit patients with cardiac arrest and pulseless electrical activity of unknown or presumed cardiovascular cause. METHODS: Patients who were older than 16 years of age and who had more than one minute of pulseless electrical activity that was unresponsive to initial therapy outside the hospital or in the emergency department were eligible. Patients were randomly assigned to receive 100 mg of t-PA or placebo intravenously over a 15-minute period in a double-blind fashion. Standard resuscitation was then continued for at least 15 minutes. The primary outcome was survival to hospital discharge. RESULTS: During the study period, 1583 patients with cardiac arrest were treated and 233 patients were enrolled (117 in the t-PA group and 116 in the placebo group). The characteristics of the patients in the two groups were similar. One patient in the t-PA group survived to hospital discharge, as compared with none in the placebo group (absolute difference between groups, 0.9; 95 percent confidence interval, -2.6 to 4.8; P=0.99). The proportion of patients with return of spontaneous circulation was 21.4 percent in the t-PA group and 23.3 percent in the placebo group (absolute difference between groups, -1.9; 95 percent confidence interval, -12.6 to 8.8; P=0.85). CONCLUSIONS: We found no evidence of a beneficial effect of fibrinolysis in patients with cardiac arrest and pulseless electrical activity of unknown or presumed cardiovascular cause. Our study had limited statistical power, and it remains unknown whether there is a small treatment effect or whether selected subgroups may benefit.

Willingness of emergency department patients with musculoskeletal complaints to participate in complementary and alternative medicine research.

BACKGROUND: The emergency department (ED) is a unique potential location for recruitment into studies of complementary and alternative medicine (CAM) therapies. We sought to determine the stated willingness of ED patients with musculoskeletal complaints to participate in CAM research for their presenting problem, and to determine the characteristics of this population. METHODS: The study was carried out in the ED of Vancouver General Hospital weekdays between 10 am and 6 pm from Oct. 16, 2000, to Nov. 21, 2000. All adults who presented with musculoskeletal complaints involving the spine, upper extremity or lower extremity, unless they had pain severe enough to impair their ability to answer questions or unless there was a language or other communication barrier, were approached by a research nurse. If it was learned that they had already been assessed by an emergency physician, they were eliminated as potential study participants. After being presented background information by the research nurse, consenting patients were asked a series of standardized questions during a 15-minute private interview prior to their assessment by an emergency physician. RESULTS: Of 107 eligible patients, 93 participated (87%). Most symptoms began on the day of presentation (44%) or in the previous week (41%). The mean age of those studied was 38 years, and 56% were male. Most presenting problems involved the ankle/foot (29%), multiple sites (19%), the lumbosacral region (14%) or the wrist/hand (14%). Seventy-six percent of patients had utilized CAM previously during their lives, and 13% were currently using CAM for their presenting problem. The majority of patients stated an informed hypothetical willingness to enroll in a CAM study of the following therapies: traditional Chinese medicine 74% (69/93: 95% confidence interval [CI] 64.1%-82.7%); chiropractic 70% (65/93: 95%CI 59.5%-79.0%); and other CAM therapies 92% (86/93: 95%CI 85.1%-96.9%). Of patients asked, 99% stated they would comply with 4 to 6 weeks of outpatient follow-up, and 70% stated they would participate in a placebo-controlled study. Logistic regression modeling, performed for secondary purposes, indicated that willingness to participate in traditional Chinese medicine or chiropractic research was independent of age, sex, educational status, pain severity or prior exposure to the modality of interest. CONCLUSIONS: ED patients with musculoskeletal complaints have a high stated willingness to participate in CAM research, even if this involves outpatient follow-up or a placebo-controlled design. ED-based CAM research appears feasible and should be pursued.