512

References

1. Hunt GS, Spencer MT, Hays DP. Etomidate and midazolam for procedural sedation: prospective, randomized trial. Am J Emerg Med 2005;23:299 – 303.
2. Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED Procedural sedation and analgesia. Am J Emerg Med 2003;21:556 – 8.
3. Falk J, Zed PJ. Etomidate for procedural sedation in the emergency department. Ann Pharmacother 2004;38:1272 – 7.

Does aging influence quality of care for acute myocardial infarction in the prehospital setting?

Elderly patients with acute myocardial infarction

To the Editor,

The primary goal of prehospital management in acute myocardial infarction (AMI) is to reduce the delay of reperfusion therapy. Quality of care of AMI is known to be lower for elderly patients, particularly because of disparities in the access to acute reperfusion therapy and the lower proportion of patients receiving adjunctive treatments [1,2]. A recent trial showed that this nonoptimal therapy for patients aged 80 years and older is already present in the ED [3]. The aim of this study was to evaluate whether our quality of care in Elderly people with AMI was altered or not during the prehospital setting.

This prospective, observational study was conducted in our Emergency Medical Service department, covering an area of 290172 inhabitants during a period of 3 years. The survey was part of the regional AMI registry, supported by the Regional Medical Board, which originates from the Ministry of Health. mobile intensive care units (MICU) are physician staffed (French EMS system SAMU), who provide on-scene diagnosis of AMI and initiate reperfusion therapies. Patients were enrolled by the physician of the MICU when diagnosis of AMI was established. Inclusion criteria for Reperfusion strategy were the presence of a typical chest pain associated with ST elevation in 2 contiguous leads or a new Left bundle branch blockade on the electrocardiogram. Reperfusion strategy consisted of prehospital thrombolysis or primary angioplasty. The following data were collected: demographic characteristics, reperfusion strategy, adjunctive treatment, and different time intervals. Results are reported as mean values F SD and percentages. Statistical analysis was performed using an analysis of variance for quantitative data and a Yates-corrected v² test for qualitative data. A P value of less than .05 was considered the threshold for significance.

Of the 149 patients included, 18 (12 %) were aged 80 years or older. All patients aged less than 80 years had reperfusion therapy, whereas this was the case in 72% (n = 13) of patients aged 80 or older ( P b .001). There was no significant difference in the proportion of patients receiving aspirin (95% vs 94%) or intravenous analgesics (60% vs 39%) in the 2 groups. For patients undergoing primary angioplasty, time

Correspondence

from arrival of MCIU to hospital admission (64 F 19 vs 67 F 14 minutes), time from arrival of MCIU to Arterial puncture (96 F 49 vs 98 F 26 minutes), and time from arrival of MICU to balloon inflation (105 F 26 vs 106 F 22 minutes) were similar in both groups (young vs elderly, respectively).

These results confirm and extend those of previous studies, which show that patients aged more than 80 years are proposed for reperfusion therapy less frequently than those aged less than 80 years. Possible explanations have been suggested: fear of increased risk of therapy-related side effects or therapeutic nihilism toward older patients [3]. Nevertheless, adjunctive therapies were not observed to be less used, and when a reperfusion therapy was decided, quick admission in catheter laboratory was not delayed.

F.X. Duchateau MD

A. Ricard-Hibon MD

M.L. Devaud MD

A. Burnod MD

J. Mantz MD, PhD

Department of Anaesthesiology and Intensive Care

Beaujon University Hospital 92110 Clichy, France

E-mail address: [email protected] doi:10.1016/j.ajem.2005.12.001

References

1. Barakat K, Wilkinson P, Deaner A, et al. How should age affect management of acute myocardial infarction? Lancet 1999;353:955 – 9.
2. Rathore SS, Mehta RH, Wang Y, et al. Effects of age on the quality of care provided to older patients with acute myocardial infarction. Am J Med 2003;114:307 – 15.
3. Magid DJ, Masoudi FA, Vinson DR, et al. Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients. Ann Emerg Med 2005;46:14 – 21.

An unusual cause of iatrogenic bladder rupture

To the Editor,

Spontaneous bladder rupture is a rare event. We describe a case that occurred after a continuous normal saline irrigation and presented an iatrogenic bladder rupture.

A 64-year-old woman presented with a history of cervical cancer with radiation therapy 3 years ago. She was disease- free since completing therapy. She was admitted to our emergency department with the chief complaint of abdominal pain, nausea, and gross hematuria for 4 days. On arrival, she was febrile to 39.28C (102.68F). Her blood pressure was 74/35 mm Hg with a heart rate of 119 beats/min and a respiratory rate of 24 breaths/min. Physical examination was notable for a distended abdomen that was diffusely tender, and Transabdominal ultrasound suggested a distended bladder with a thickened wall. An indwelling urinary catheter was

Correspondence 513

placed with gross hematuria. The main laboratory finding evaluation revealed the following: glucose 210 mg/dL, glutamic-oxaloacetic transaminase 35 U/L, serum urea nitrogen 68 mg/dL, serum creatinine 3.0 mg/dL, sodium

124 mEq/L, serum potassium 5.5 mEq/L, hemoglobin

10.5 gm/dL, hematocrit 30%, white blood cell 16800/lL, and microscopic pyuria. Her platelets were adequate and there was no evidence of coagulopathy. Arterial blood gas on room air revealed pH 7.25, Pco₂ 25.2 mm Hg, Po₂ 62.5 mm Hg, and HCO₃ 15.2 mmol/L. The patient was admitted at the intensive care unit for fluid resuscitation. Cystoscopic examination showed Blood clots in the dome of the bladder. A 3-way Foley catheter was in place with a continuous normal saline irrigation. On the following day, she had signs of peritonitis. An emergency computed tomography scan revealed free fluid and air in the peritoneal cavity around the bladder, signifying intraperitoneal rupture (Fig. 1). An urgent subsequent laparotomy revealed a 3-cm bladder laceration in the fundus extending posteriorly. The edges were trimmed and the defect was repaired in 2 layers. After the surgery, the patient made an uneventful recovery. Biopsy of the region surrounding the perforation revealed chronic inflammation, necrosis, and fibrosis consistent with previous radiation with no evidence of malignancy.

Blunt trauma to the abdomen is the most common cause

of bladder rupture. The other causes are previous enter- ocystoplasty, pelvic radiotherapy, undiagnosed bladder tumor, or urinary obstruction during catheterization. Spon- taneous rupture of the urinary bladder is a Rare condition in which the urinary bladder wall tears and releases urine into the abdominal cavity associated with significant morbidity and mortality [1]. Intraperitoneal rupture has significantly higher morbidity and mortality than extraperitoneal rupture because of urine-induced peritonitis.

Iatrogenic rupture of the bladder secondary to a contin- uous normal saline irrigation is even more rare. It is usually seen in association with conditions such as neurogenic dys- function [2]. Moreover, it should be suspected in patients with a history of radiotherapy to the pelvis [3]. Hemorrhagic cys- titis can occur 6 months to 10 years after pelvic radiation therapy with moderate to severe persistent rates of hematuria as 3% to 5% after radiotherapy for pelvic malignancies [4]. Acute hemorrhagic cystitis is a gross hematuria and symp- toms of cystitis. Severe hemorrhagic cystitis may require aggressive management when associated with a significant blood loss. Continuous bladder irrigation may diminish hemorrhagic cystitis and can help prevent urinary tract obstruction by flushing out blood clots. However, despite irrigation with a 3-way Foley catheter, obstruction of the catheter caused by blood clot still occurs. Clinically, check the inflow and outflow line periodically for kinks to make sure the normal saline is running freely. A pressure of more than 300 cm H₂O is required to rupture a normal bladder [5]. The drip rate of irrigation should appear equal to the rate of drip into drainage Foley bag to prevent bladder overdistension. Using continuous bladder irrigation, bladder

Fig. 1 Computed tomographic scan revealed free fluid and air (arrow) in the peritoneal cavity around the bladder, signifying intraperitoneal rupture.

rupture is highly suspected by inability to retrieve the total amount of the irrigant.

Aming Chor-Ming Lin MD

Emergency Department Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan, ROC Department of Intensive Care Unit

Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan, ROC E-mail address: [email protected]

Guang-Dar Juang MD

Department of Urology Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan, ROC

Chien-Hsien Huang MD

Department of Medicine Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan, ROC

Cheng-Yu Tso RN

Department of Intensive Care Unit Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan, ROC

doi:10.1016/j.ajem.2005.11.018

References

1. Carmon M, Nissan A, Pappo I, Perlberg S, Seror D, Haskel Y. Spontaneous rupture of the urinary bladder complicated by extensive fasciitis: the importance of a high index of suspicion. Urol Int 1994;52(1):38 – 40.

514 Correspondence

1. Ottesen M, Iversen JT. Spontaneous bladder perforation–a rare complication of neurogenic bladder dysfunction. Ugeskr Laeger 1993; 4:2352 – 3.
2. Fujikawa K, Miyamoto T, Ihara Y, Matsui Y, Takeuchi H. High incidence of severe urologic complication following radiotherapy for cervical cancer in Japanese women. Gynecol Oncol 2001;80:21.
3. Corman JM, McClure D, Pritchett R, Kozlowski P, Hampson NB. Treatment of radiation induced hemorrhagic cystitis with Hyperbaric oxygen. J Urol 2003;169(6):2200 – 2.
4. Peters PC. Intra-peritoneal rupture of the bladder. Urol Clin North Am 1989;16:279 – 82.

Establishing a pharmacy presence in the ED

To the Editor,

Over the last 20 years, clinical pharmacists have been shown to reduce the number of prescribing errors, improve patient outcomes, reduce medication costs, and, most importantly, reduce mortality as members of multidisciplin- ary teams [1-4]. As far back as 1977, the provision of clinical pharmacy services in the ED was demonstrated to be well received and beneficial to both physicians and patients [5]. Clinical pharmacy services in the ED are used more than any other consult service when available 24 hours a day and can lead to cost savings of more than $93000 per year [6,7].

Currently, the Department of Pharmacy Services at the University of Kentucky, Chandler Medical Center does not have a consistent presence in the ED. Although medication distribution is facilitated through a central pharmacy and an automated dispensing system, limited clinical pharmacy services are provided upon special request and/or emergency situations (eg, cardiac arrest and stroke response). The opportunity for a clinical pharmacist to intervene and impact clinical pharmacotherapy decisions made in the ED may translate into an enhanced quality of care and cost savings for the institution. To evaluate this hypothesis, an innovative rotation was established for the two critical care residents in the ED over a 2-month period.

The residents were to provide clinical pharmacy services to ED patients through cardiac arrest team participation, pharmacotherapy responses, and pharmacokinetic monitor- ing. They were also asked to provide educational services for physicians, nurses, and patients including medication counseling. The residents were instructed to obtain medi- cation histories on targeted patients and services admitted to the hospital through the ED. Targeted services were defined as those that did not have a clinical pharmacist rounding with the team or on surgical services. Targeted patients were defined as transplant, HIV, or complex pharmacotherapy patients on any service. These objectives were largely based on the available data linking these activities to improved patient outcomes [4]. Residents were

Meeting Presentation: Kentucky Society of Hospital Pharmacists, Louisville, KY, November 2005; American College of Clinical Pharmacy, San Francisco, CA, October 2005.

expected to provide accurate and appropriate dosing recommendations and medication monitoring of antibiotics, as well as encouraging the judicious use of empiric antibiotic therapy. Another goal was to improve upon the use of cost-effective initial medication therapy when appropriate. The two residents participated in month-long rotations during April and May 2005. These residents provided clinical pharmacy services Monday through Saturday from 1600 to 2400 hours. The residents were expected to provide one educational in-service per month to ED physicians and nurses. All pharmacy interventions provided while on the ED rotation were documented in the pharmacy computer system (WoRx). They were also given the responsibility of documenting and facilitating the time from Antibiotic prescribing to medication administration. This was based upon multiple reports of medication delivery delays and was an attempt to both quantify and rectify the problem.

Overall, the pharmacy residents were well received by the medical and nursing personnel. The residents provided one educational in-service each month. A total of 201 inter- ventions were documented in the pharmacy computer system by the residents over the 2-month period. Typically, only interventions resulting in a pharmacist written order, or note, in the medical record resulted in documentation in the computer system; other interventions were documented separately. Ninety-three medication histories were per- formed during the 2 months and 103 pharmacokinetic dosing interventions were made. Emergency department interventions are described in Fig. 1 with the number of intervention the residents devoted to each activity. The data collected concerning medication facilitation are portrayed in Fig. 2. The average time from medication prescribing to administration was 63.5 minutes. The greatest delay (25.3 minutes) occurred from entry into the WoRx system to delivery time.

The provision of clinical pharmacy services is a well- established means for enhancing patient care, reducing medication costs, and decreasing mortality. The extension of these services to the ED is a natural and proven progression that has demonstrated similar benefits. Over the 2-month period, approximately 75% of the residents’ time was equally divided between obtaining medication histories, dosing medications, and providing pharmacother- apy consults. The residents were well received by both the medical and nursing staff and requests have been made for a continuous pharmacy presence. To enhance patient care, data were collected concerning the time from medication pre- scribing to administration, a delay that was found to be more than 60 minutes. The greatest delay in time appeared to be from prescription Order entry to ED delivery. Although there exists no baseline comparison for these data, nursing personnel commented that the presence of a clinical pharmacist greatly expedited this process. This initiative has resulted in the development of an elective rotation for PGY1 and PGY2 pharmacy residents as well as the recent