Annals of emergency medicine
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Randomized Controlled Trial Comparative Study
Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department.
We compare intravenous midazolam and droperidol for the onset of sedation of acutely agitated patients in the emergency department (ED). ⋯ There is no difference in onset of adequate sedation of agitated patients using midazolam or droperidol. Patients sedated with midazolam may have an increased need for active airway management.
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Heart failure causes substantial morbidity and mortality in the United States and accounts for a higher proportion of Medicare costs than any other disease. Most of these costs result from the high rate of hospital admissions and protracted length of stay associated with episodes of acute decompensation of heart failure. Thus, effective clinical strategies to obviate hospitalization and readmission can result in substantial savings. ⋯ In institutions with specialized heart failure observation units, patients are triaged to this setting shortly after presentation to the emergency department (ED), and clinic referrals can be directed to this unit after minimal ED evaluation. Aggressive follow-up is also arranged at discharge. Recent additions to the therapeutic armamentarium and future advances in diagnostics and monitoring will continue to improve patient care and prevent avoidable hospitalizations.
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Current risk stratification tools do not identify very-low-risk patients who can be safely discharged without prolonged emergency department (ED) observation, expensive rule-out protocols, or provocative testing. We seek to develop a clinical prediction rule applicable within 2 hours of ED arrival that would miss fewer than 2% of acute coronary syndrome patients and allow discharge within 2 to 3 hours for at least 30% of patients without acute coronary syndrome. ⋯ The Vancouver Chest Pain Rule for early discharge defines a group of patients who can be safely discharged after a brief evaluation in the ED. Prospective validation is needed.
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Comparative Study
Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure.
Although chest radiography is quick and inexpensive, previous research suggests that it is often misleading in emergency department (ED) patients with decompensated heart failure, resulting in misdiagnosis and inappropriate treatment. This study determines the rate of negative chest radiography results in patients found to have disease and the potential contribution of negative findings to a diagnosis discordant with heart failure by an emergency physician. ⋯ Approximately 1 of every 5 patients admitted from the ED with acute decompensated heart failure had no signs of congestion on chest radiography. Patients lacking signs of congestion on ED chest radiography were more likely to have an ED non-heart failure diagnosis than patients with signs of congestion. Clinicians should not rule out heart failure in patients with no radiographic signs of congestion.