Objective-To quantify the change in door to needle time when delivery of thrombolytic treatment of acute myocardial infarction was changed from the coronary care unit to the emergency department. Design-A comparative observational study using prospectively collected data. Setting-Coronary care unit and emergency department of an Australian teaching hospital. Participants-89 patients receiving thrombolysis in coronary care unit between June 1994 and January 1996, and 100 patients treated in the emergency department between April 1997 and May 1998. Interventions-From April 1997, by agreement between cardiology and emergency medicine, all patients with acute myocardial infarction receiving thrombolysis were treated by emergency physicians in the emergency department. Main outcome measure-Door to needle time measured from time of arrival at the hospital to start of thrombolysis. Other outcomes included pain to needle time and mortality. Results-Median door to needle times were less for patients treated in the emergency department than in the coronary care unit (37 minutes, 95% confidence interval (CI) 33 to 44 v 80 minutes, 95% CI 70 to 89, respectively; p < 0.0001). Door to needle time was under 60 minutes in 83% of emergency department patients and 26% of coronary care unit patients (57% diVerence, 95% CI 45% to 69%; p < 0.0001). Median pain to needle time was less for emergency department patients than for coronary care unit patients (161 minutes, 95% CI 142 to 177 v 195 minutes, 95% CI 180 to 209; p = 0.004); times of less than 90 minutes occurred in 18% of emergency department patients v 1% of coronary care unit patients (17% diVerence, 95% CI 9% to 25%; p < 0.05). Overall mortality was similar in patients treated in the emergency department and the coronary care unit. Conclusions-With a collaborative interdepartmental approach, thrombolytic treatment of acute myocardial infarction was more rapid in the emergency department, without compromising patient safety. This should improve the outcome in patients with infarcts treated with thrombolytic agents.

Objective: To determine the safety and efficacy of midazolam premedication to minimize the subjective adverse effects of adenosine. Methods: Double‐blind prospective randomized controlled trial of patients presenting to an urban emergency department. Included were a convenience sample of patients who would have received adenosine by the existing department protocol. Exclusion criteria were pregnancy, benzodiazepine allergy, regular benzodiazepine medication, alcoholism, altered mental state (precluding informed consent), and age less than 18 or greater than 65 years. Subjects received either 1.5 mg of intravenous midazolam or normal saline placebo 5 min prior to the administration of adenosine. Side‐effect recall was judged by a questionnaire at 1 h and 24 h postadenosine administration. Results: A total of 34 patients were recruited into the trial, 16 in the placebo group and 18 in the midazolam group. The groups were well matched for demographics, treatment and outcome. There was a significant reduction in the midazolam group for complaint scores of palpitations (P = 0.04) and chest pain (P = 0.02) and a trend to reduction in complaint scores for most other parameters. There were no adverse outcomes in any of the patients studied. Conclusions: Co‐administration of midazolam can safely reduce the recall of the unpleasant adverse effects of adenosine. Its use may be most appropriate in patients who are particularly anxious or have had previous adverse experiences with adenosine.