Recombinant tissue plasminogen activator: in my community hospital ED, will early administration of rt-PA to patients with the initial diagnosis of acute ischemic stroke reduce mortality and disability?

Ethics and consent to treat issues in acute stroke therapy

Consent to treat with thrombolytic therapy for acute ischemic stroke presents an ethical dilemma for hospitals, physicians, patients, and their families. This article presents four aspects of this controversial topic and provides recommendations for conditions that allow for ethical consent to treat.

Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature

STUDY OBJECTIVES

There is some evidence that magnesium, when infused into asthmatic patients, can produce bronchodilation in addition to that obtained from standard treatments. This systematic review examined the effect of intravenous magnesium sulfate used for patients with acute asthma managed in the emergency department.

METHODS

Only randomized controlled trials were eligible for inclusion. Studies were included if patients presented with acute asthma and were treated with intravenous magnesium sulfate versus placebo. Trials were identified from the Cochrane Airways Review Group register, which consists of a combined search of EMBASE, MEDLINE, and CINAHL databases and hand-searching of 20 key respiratory journals. Bibliographies from included studies and known reviews were searched. Primary authors and content experts were contacted. Data were extracted and methodologic quality was assessed independently by 2 reviewers. Missing data were obtained from authors.

RESULTS

Seven trials (5 adult, 2 pediatric) involving a total of 668 patients were included. Overall, admission to hospital was not statistically reduced using magnesium sulfate (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.09 to 1.02). In the severe subgroup, admissions were reduced in those receiving magnesium sulfate (OR 0.10, 95% CI 0.04 to 0.27). Overall, patients receiving magnesium sulfate demonstrated nonsignificant improvements in peak expiratory flow rates (PEFR) when all studies were pooled (weighted mean difference [WMD] 29 L/min, 95% CI -3 to 62). In studies of patients with severe acute asthma, PEFR WMD improved by 52 L/min (95% CI 27 to 78) favoring magnesium sulfate treatment. The absolute FEV(1) also improved by 10% predicted (95% CI 4 to 16) in patients with severe acute asthma. No clinically important changes in vital signs or side effects were reported.

CONCLUSION

Current evidence does not clearly support routine use of intravenous magnesium sulfate in all patients with acute asthma presenting to the ED. However, magnesium sulfate appears to be safe and beneficial for patients who present with severe acute asthma. Practice guidelines need to be changed to reflect these results.

An evidence based approach to diagnostic testing in emergency medicine

Virtually all physicians involved in clinical practice are realizing that the delivery of highest caliber medical care requires a blend of appropriate training, adequate experience, the proper amount of "art," empathetic interpersonal skills, respect for patient preferences, and, more than ever, an evidence-based approach firmly grounded in methodologically sound scientific studies. This article provides an overview of the issue, explaining the evidence-based approach to the many diagnostic studies discussed in the ensuing articles.