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