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Chen ZM, Sandercock P, Counsell C, et al. Indications for early aspirin use in acute ischemic stroke. Stroke 2000; 31:1,240.
You should give all patients with suspected stroke aspirin on arrival to the ED, according to this study, which combines results of the Chinese Acute Stroke Trial and the International Stroke Trial. Giving aspirin to stroke patients can reduce the risk of recurrent strokes, say the researchers.
Starting daily aspirin promptly in patients with suspected acute ischemic stroke reduces the immediate risk of further stroke or death in the hospital and decreases the overall risk of death, says the study. Two large randomized trials with 20,000 patients each were used. Data from 40,000 patients were analyzed and confirmed that early aspirin benefits
a wide range of patients.
The study shows that aspirin provides an immediate prevention benefit in the days and weeks following the stroke.
Clinicians might have been reluctant to give aspirin immediately to stroke patients because of concern that it might cause bleeding in the brain, suggest the researchers. The study found that aspirin was much safer than initially anticipated, with the benefits outweighing the risk for all types of patients studied.
Here are key findings:
• Consider aspirin for all patients who present with signs and symptoms of acute ischemic stroke, provided that no strong contraindications are apparent, and that hemorrhagic stroke can be excluded with reasonable probability.
• The urgency of other treatments for ischemic stroke, such as fibrinolytic therapy, might cause aspirin to be overlooked.
• Because aspirin has been shown to be effective in the long-term secondary prevention of stroke after hospital discharge, you should administer aspirin promptly even to patients who present more than 48 hours after onset of symptoms.
• The ability of aspirin to prevent recurrent ischemic stroke is about as great for patients with atrial fibrillation as those without.
For maximum benefit, aspirin should be started promptly after the onset of suspected ischemic stroke and continued indefinitely, say the researchers.
Singer AJ, Stark, MJ. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: A randomized double-blind trial. Acad Emerg Med 2000; 7:751-756.
Triage nurses should apply topical anesthetics to simple lacerations, according to this study from the State University of New York at Stony Brook. Researchers looked at 43 patients, 22 of whom received LET (lidocaine 2%, epinephrine 1:1000, tetracaine 2%) at triage and 21 placebo. Lacerations in the LET group were more often adequately anesthetized, and LET patients had less pain from injection than the placebo group, according to the study’s findings.
Topical application of an anesthetic solution such as LET to lacerations by triage nurses is both feasible and effective in reducing the pain of subsequent lidocaine injection, say the researchers.
This method also might have the potential to reduce the patient’s ED length of stay, they suggest. "It seems likely that having lacerations ready for injection when the emergency practitioner first evaluates them would indeed save time," they write.
They says the alternatives would be for the emergency practitioner to apply a topical anesthetic and then wait for an additional 15-30 minutes before onset of action, or proceed with lidocaine injection and wound closure without the benefit of topical anesthesia.
The researchers suggest the following:
• having triage nurses apply a topical anesthetic as soon as the patient presents to the ED;
• having triage nurses identify lacerations that necessitate some form of primary closure;
• carefully instructing nurses on the appropriate indications and contraindications for the use of LET;
• using LET instead of other topical anesthetics.
"The advantages of LET over TAC [tetracaine, adrenaline, and cocaine] and EMLA [eutectic mixture of local anesthetics] are its low cost, safety, and lack of administration issues associated with use of a controlled substance," say the researchers.
Meischke H, Mitchell P, Zapka J. The emergency department experience of chest pain patients and their intention to delay care seeking for acute myocardial infarction. Progress in Cardiac Nursing 2000; 15:50-57.
Reassure chest pain patients who are sent home that they did the right thing to come to the ED for their symptoms, according to this study, which was part of the Rapid Early Action for Coronary Treatment (REACT) research. The study was designed to test the effects of a community education program on reducing prehospital delays in patients with heart attack symptoms.
A telephone survey was conducted for 426 ED patients with a chief complaint of chest pain who were released from the ED. The patients were asked about their satisfaction with ED staff communication and their intention to delay prompt action for acute myocardial infarction (AMI) symptoms in the future.
The results showed that the less education patients had, the less sure they felt that going to the ED had been "the right thing to do," the greater their embarrassment, and the greater their intention to delay action for future symptoms. Conversely, patients who were reassured by ED staff that they did the right thing to come to the ED were less likely to report intentions to delay seeking care in the future. The researchers recommend the following:
• giving counseling to ED patients with chest pain who are sent home about the importance of seeking care for chest pain, even if it turns out not to be life-threatening;
• being sensitive to feelings of embarrassment and trying to mitigate these feelings;
• improving ED staff communication;
• targeting patients with lower education levels about the importance of fast action to seek care for AMI.
Because about half of all chest patients are sent home from the ED, many patients are at risk for not responding promptly for a future chest pain event, say the researchers.
"It is critical that ED staff, including emergency medical services staff, praise chest pain patients for their actions and communicate to patients that AMI symptoms are ambiguous and require evaluation by a physician, and that fast action is the only appropriate course of action," they say.