LLSA 2012

CONTEXT: Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD); however, their optimal dose and route of administration are uncertain. OBJECTIVE: To compare the outcomes of patients treated with low doses of steroids administered orally to those treated with higher doses administered intravenously. DESIGN, SETTING, AND PATIENTS: A pharmacoepidemiological cohort study conducted at 414 US hospitals involving patients admitted with acute exacerbation of COPD in 2006 and 2007 to a non-intensive care setting and who received systemic corticosteroids during the first 2 hospital days...

No abstract text is available yet for this article.

OBJECTIVES: Serum lactate values in the emergency department (ED) have been associated with mortality in diverse populations of critically ill patients. This study investigates whether serum lactate values measured in the ED are associated with mortality in older patients admitted to the hospital, both with and without infections. METHODS: This is a retrospective cohort study performed at two urban teaching hospitals. The study population includes 1,655 older ED patients (age>or=65 years) over a 3-year period (2004-2006) who had serum lactate measured prior to admission...

Airway management in obese adults can be challenging, and much of the literature on this subject focuses on elective surgical cases, rather than acutely ill patients. In this article, we review the emergency department evaluation of the airway in obesity, discussing anatomy, physiology, and pharmacology. In addition, we describe techniques and devices used to improve intubating conditions in the obese patient. After our review of the relevant literature, we conclude that research in this particular area of acute care remains in its infancy...

STUDY OBJECTIVE: To synthesize the evidence on the effect of a bolus dose of etomidate on adrenal function, mortality, and health services utilization compared with other induction agents used for rapid sequence intubation. METHODS: We developed a systematic search strategy and applied it to 10 electronic bibliographic databases. We hand searched journals; reviewed conference proceedings, gray literature, and bibliographies of relevant literature; and contacted content experts for studies comparing a bolus dose of etomidate with other induction agents...

BACKGROUND: Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other. METHODS: In this multicenter, randomized trial, we assigned patients with shock to receive either dopamine or norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. When blood pressure could not be maintained with a dose of 20 microg per kilogram of body weight per minute for dopamine or a dose of 0...

CONTEXT: Acute onset of monocular floaters and/or flashes represents a common presentation to primary care physicians, and the most likely diagnosis is posterior vitreous detachment (PVD). A significant proportion of patients with acute PVD develop an associated retinal tear that can lead to retinal detachment and permanent vision loss if left untreated. OBJECTIVE: To quantify the association between relevant clinical variables and risk of retinal tear in patients presenting with acute-onset floaters and/or flashes and PVD...

No abstract text is available yet for this article.

This clinical policy from the American College of Emergency Physicians focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED)with community-acquired pneumonia. It is an update of the 2001 clinical policy for the management and risk stratification of adult patients presenting to the ED with community-acquired pneumonia. A subcommittee reviewed the current literature to derive evidence-based recommendations to help answer the following questions: (1) Are routine blood cultures indicated in patients admitted with community-acquired pneumonia? (2) In adult patients with community-acquired pneumonia without severe sepsis, is there a benefit in mortality or morbidity from the administration of antibiotics within aspecific time course? The evidence was graded and recommendations were given based on the strength of evidence...

No abstract text is available yet for this article.

BACKGROUND: Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients. METHODS: In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France...

STUDY OBJECTIVE: We developed and implemented an institutional protocol aimed at reducing crowding by admitting boarded patients to hospital inpatient hallways. We hypothesized that transfer of admitted patients from the emergency department (ED) to inpatient hallways would be feasible and not create patient harm. METHODS: This was a retrospective cohort study in a suburban, academic ED with an annual census of 70,000. We studied consecutive patients admitted from our ED between January 2004 and January 2008...