The purpose of this study was to determine the frequency of acute myocardial infarction in patients presenting to the ED with cocaine-associated chest pain syndromes. Patients were included in the study if they had a documented history of cocaine use within the week prior to presentation or a urine toxicology screen that revealed cocaine or cocaine metabolites; had a chief complaint of anterior, precordial, or left-sided chest discomfort less than 12 hours in duration; and were aged 18 years or older.

Of the 250 patients included in the study, 77% of the patients were male, 84% African American, 10% were Caucasian, and 77% used tobacco. In addition, 34% had a family history of coronary artery disease and 26% had hypertension. 22% described their chest pain as sharp or stabbing, only 14% had a pleuritic component to their chest pain, and 55% described their chest pain as a pressure, tightness, or squeezing. In addition, 62% had shortness of breath, 48% had diaphoresis, and 28% had nausea. This study found that only 6% of the 250 patients had an acute myocardial infarction.

Although low-risk groups of traditional patients who may be safely admitted to intermediate care units have been identified, a group of cocaine-associated chest pain patients who can be safely released from the ED based on explicit criteria has not been validated. Hollander et al have suggested that patients without ischemic ECGs who have negative marker studies and no complications during a 12-hour observation period have only a 1.6 per 1,000 patient risk of subsequent adverse events. This study confirms these data. No patient had an adverse event more than 12 hours after ED arrival. Studies regarding the safety of a nine-hour rule-out protocol followed by stress testing in low-risk patients are forthcoming.

Clinical Policy for the Management and Risk Stratification of Community-acquired Pneumonia in Adults in the Emergency Department.

This policy outlines an approach that emphasizes key clinical information to determine the severity of disease in community acquired pneumonia. Clinical judgement may be complemented by this risk stratification to determine whether a patient can be treated as an outpatient or requires admission. This policy is intended for patients 18 years of age or older with clinical and radiologic evidence of pneumonia. Patients arriving at the ED from nursing homes are included. Patients excluded from this policy are those who are critically ill or who require respiratory support in the ED. Also excluded are patients with hospital-acquired pneumonia, patients with pneumonia rehospitalized within 30 days of their previous hospitalization, patients who are pregnant, and patients with HIV or who are otherwise immunocompromised.

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