bluuebunny/crossref_metadata_2025 huggingface dataset:
Flaccid paralysis due to hyperkalaemia
Authors: HORE CRAIG
Published: August 2010

A 68 year old patient presented to the emergency department with ascending muscular weakness progressing to flaccid quadriplegia and imminent respiratory paralysis. The cause was profound hyperkalemia and the patient responded quickly to emergency management, and went on to make an uncomplicated recovery.
Strangulated gastrothorax mimicking tension pneumothorax
Authors: SMART N G , WORLEY P J
Published: August 2010

A case of strangulated tension gastrothorax in a 34 year old man with a past history of Nissen fundoplication and asthma is described. Presenting with acute respiratory distress, decreased breath sounds and cardiovascular collapse, the chest radiograph was initially read as a tension pneumothorax. Tube thoracostomy resulted in clinical improvement by perforating and decompressing the stomach. The initial treatment of choice when a tension gastrothorax is identified is placement of a nasogastric tube which is both diagnostic and therapeutic. Thoracostomy by needle or chest drain may result in clinical improvement despite soiling of the pleural space and is indicated for patients in extremis when a nasogastric tube cannot be passed.
Transcutaneous carbon dioxide monitoring in the emergency department: a pilot study
Authors: KELLY ANNE‐MAREE , HANSON DALE
Published: August 2010

Study Objective: Pilot study to assess the potential place of transcutaneous carbon dioxide monitoring technology in the emergency department.

Design: Prospective

Setting: Urban emergency department.

Type of participants: 30 patients requiring arterial blood gas analysis as part of their management.

Measurement and main results:

Subjects with capillary return time less than two seconds: Correlation of PTCCO2 versus PACO2 0.93, bias 0.2, precision 5.9.

Subjects with capillary return time of greater than two seconds: Correlation PTCCO2 versus PACO2 0.46, bias ‐6.6, precision 20.

Conclusions:

Transcutaneous carbon dioxide measurements are unreliable in low flow states as defined by capillary return time of greater than two seconds.

Measurement of transcutaneous carbon dioxide has the following potential uses in the emergency department:

a) Monitoring carbon dioxide in patients with chronic airway limitation receiving oxygen therapy.

b) A screening test in respiratory patients with normal peripheral perfusion.
Prehospital resuscitation and sudden cardiac death
Authors: FITZGERALD MARK C
Published: August 2010

Rates of survival horn pre‐hospital cardiac arrest are often used to judge the quality of emergency medical systems. Despite many advances in technology and pharmacotherapy over the last two decades, overall survival rates in most systems remain disappointing. Objective analysis of different systems of care and associated outcomes has been hampered by a lack of uniform data reporting. Attempts to improve survival must focus on the key to resuscitation from sudden cardiac death, that is rapid response defibrillation.
Phosphine gas poisoning
Authors: FATOVICH DANIEL M , GRAYDON ROBERT H , PRENTICE DAVID A , HIRSCH RONALD L
Published: August 2010

Phostoxin is a fumigant used in rural areas. We report a case of phostoxin ingestion which resulted in the release of lethal phosphine gas.

The patient developed a profound metabolic acidosis and cardiovascular depression and died. During treatment and after death, he continued to emit the noxious gas which was dangerous to staff, and resulted in evacuation of the emergency department. Such events tend to be associated with myth and hysteria and the lack of ready access to reliable information. They represent a unique challenge to the emergency physician.
Successful treatment of 75 patients in status epilepticus with intravenous midazolam
Authors: GALVIN G MICHAEL , JELINEK GEORGE A
Published: August 2010

Seventy‐five consecutive patients attending the Emergency Department at Fremantle Hospital in status epilepticus were treated with intravenous midazolam. All seizures ceased without other therapy, after an average dose of 0.1 mg/kg midazolam. Seven percent of patients had a further seizure in the Emergency Department, a rate comparable to other anticonvulsants.

Midazolam is a safe, effective agent for the treatment of status epilepticus, with possible advantages over currently accepted treatment.
Dog bites in Tea Tree Gully
Authors: KELLY ANNE‐MAREE , FENSAK SARA K
Published: August 2010

Dog bite injury is a common reason for presentation to emergency departments. However the nature of this problem in Australia has not been closely studied and a number of unresolved questions remain regarding management options. This prospective study of 101 cases was undertaken to collect demographic information about victims and assailants, to describe the spectrum of injury seen and to report outcome following a standard management protocol.

In common with other studies, young males were bitten most frequently, usually by German Shepherds, Heelers and Terriers. Nearly half (48%) of the facial injuries occurred in children under 10 years old. The infection rate in this study, using wound cleansing and prophylactic penicillin in all cases, was only 4%. Wound swabs on presentation were unhelpful. Controversies still exist regarding wound closure and the use of prophylactic antibiotics.
Altitude illness
Authors: CURRY CHRIS
Published: August 2010

Increasingly people are visiting high mountain regions, exposing themselves to the risks of altitude‐related illnesses including acute mountain sickness, high altitude pulmonary oedema and high altitude cerebral oedema. This article reviews the pathophysiology, clinical features and treatment of these disorders.
Microcatheter aspiration of spontaneous pneumothoraces in an emergency department
Authors: CRUSE DAVID , JELINEK GEORGE A
Published: August 2010

Objective: To assess the efficacy of microcatheter aspiration (MCA) of spontaneous pneumothoraces in the Emergency Department of Fremantle Hospital.

Methods: From 1986–1993, patients less than 45 years old with a first spontaneous pneumothorax on chest X‐ray of greater than 20% were treated with MCA. Those with underlying lung disease or tension were excluded. MCA was performed with a 16G central venous pressure catheter. Patients were reassessed radiologically at six and 24 hours. The procedure was considered successful if there was less than 15% residual pneumothorax after aspiration and at 24 hours.

Results: Of thirty patients studied, 22 (73%) had successful aspiration and were discharged the following day.

Conclusions: Literature review and results of this study suggest that MCA is appropriate initial treatment for first or subsequent spontaneous or iatrogenic pneumothoraces of 20% lung volume or more, in the absence of coexisting lung disease or tension. Most patients can be successfully treated in the Emergency Department and will not require admission. This should result in less morbidity and time in hospital.
Options in the management of spontaneous pneumothorax
Authors: KELLY ANNE‐MAREE
Published: August 2010

This paper reviews the options currently available for the management of spontaneous pneumothorax.
Methaemoglobinaemia due to nitrite poisoning
Authors: ZALSTEIN SALOMON
Published: August 2010

Objective: A case of severe acquired methaemoglobinaemia is reported. The condition is uncommon and the severity of this case is notable. The nature of the condition, its diagnosis and management are reviewed.

Clinical features: A 35 year old woman was brought to the Emergency Department by ambulance in a moribund state with an indication that she may have ingested amyl nitrite.

Interventions and outcome: The patient was treated with methylene blue, responded promptly, was admitted to the intensive care unit and subsequently discharged from hospital well.

Conclusion: Although uncommon, some poisonings are rapidly fatal. It is vital that doctors practising emergency medicine are well acquainted with such poisonings so that patients may be treated in an appropriate and timely fashion.
The effect of ambulance treatment on patient temperature normalisation
Authors: GRANTHAM HUGH , FAWCETT GLENN
Published: August 2010

The range of patient temperatures encountered in ambulance practice in winter (July to September) in Adelaide was studied using tympanic membrane infra red thermometers. The results were expressed in equivalent oral temperatures. The effectiveness of ambulance treatment in normalising hypothermia and pyrexia was also studied.

Results of 383 cases were analysed. The mean temperature was 36.4 C (oral equivalent). There was no significant difference in initial temperature with age or nature of case (trauma, medical emergency and non urgent elective cases). The temperature of patients who were initially either hypothermic or febrile was significantly normalised by ambulance treatment.

These results confirm the effectiveness of ambulance treatment for patients with abnormal temperatures, and provide a starting point for further research into improving the ambulance management of hypothermia and fever.
Childhood meningitis and Haemophilus influenzae type b vaccines
Authors: MCINTOSH E DAVID G , ISAACS DAVID
Published: August 2010

Effective vaccines against Haemophilus influenzae type b (Hib) disease in children are available. If overseas experience is any indication, the incidence of invasive Hib disease in infants and children will fall substantially over the next few years. In the absence of signs of raised intracranial pressure, lumbar puncture is generally indicated in children with suspected meningitis prior to therapy. Infants and children with suspected meningitis should be given dexamethasone preferably before or within twenty minutes of the first dose of antibiotics in order to prevent the sequelae of deafness and neurological damage. The treatment of choice for neonatal meningitis is ampicillin and cefotaxime, but the efficacy of dexamethasone in preventing long‐term sequelae in neonates is not yet established. The treatment of choice in older infants and children is cefotaxime or ceftriaxone. Antibiotic therapy should be continued for seven days for uncomplicated meningococcal meningitis and 10 days for Hib and pneumococcus in infants and children, and for 14 to 21 days for neonatal meningitis. Chemoprophylaxis of selected contacts with rifampicin is recommended.
Has Gallo proven the role of HIV in AIDS?
Authors: PAPADOPULOS‐ELEOPULOS ELENI , TURNER VALENDAR F , PAPADIMITRIOU JOHN M
Published: August 2010

The evidence that Robert Gallo and his colleagues presented on 4th May 1984 regarding HTLV‐III (HIV) isolation and the role of HIV in the pathogenesis of AIDS is critically analysed. It is concluded that the evidence does not constitute proof of the isolation of a retrovirus, that the virus is exogenous, or that the virus is causally related to AIDS.
Traumatic coronary artery fistula
Authors: CHAN BETTY S H , DOOHAN MELISSA M
Published: August 2010

Objective: To present a case of traumatic coronary artery fistula caused by blunt injury.

Clinical features: A previously healthy 20‐year‐old motor cyclist was involved in a motor vehicle accident. He suffered acute myocardial infarction secondary to a traumatic coronary artery fistula (CAF). His other injuries included a fractured left clavicle, bilateral small pulmonary contusions and pneumothoraces, pneum‐omediastinum and a small subcapsular haematoma of the liver.

Intervention and outcome: He was managed conservatively. Recovery was complicated only by pericarditis and he was well one year after the injury.

Conclusion: Traumatic CAF may result from blunt chest trauma and may be diagnosed from history, physical examination, and ECG changes. An echocardiogram should be performed in patients with positive ECG findings or the development of a new continuous murmur. Coronary angiography remains the gold standard but is rarely indicated in the acute situation. Regular follow up is required as traumatic CAF has a high incidence of late complications. With symptomatic CAF, the recommended treatment of surgical repair has a high success rate with few complications.
Trauma teams: order from chaos
Authors: MYERS COLIN T , BROWN ANTHONY F T , DUNJEY STEPHEN J , O'BRIEN DELIA A
Published: August 2010

Introduction: Trauma systems based on trauma centres have become the gold standard for trauma care in North America. The epidemiology of trauma in the United Kingdom and Australasia is significantly different. The standard of care of patients with blunt injuries in British hospitals may not be as high as in North America. There is ongoing research into the best system of care. Until convincing results are available, adoption of a trauma team approach by all hospitals receiving major trauma would be appropriate. The purpose of this paper is to provide sufficient detail of an operational trauma team to allow others to develop a similar system.

Methods: We introduced a trauma team approach in the Emergency Department of the Royal Brisbane Hospital, a tertiary referral teaching hospital. Laminated action cards detailed precise task allocation to four doctor‐nurse pairs working simultaneously. Equipment, procedures, pathology requests, radiology and clerical duties were standardised in advance. An audit form was completed after each resuscitation.

Results: In an initial review, 108 patients admitted with trauma met criteria for activation of the trauma team. Time of arrival to completion of initial resuscitation was reduced by 63 per cent and time in the department by 51 per cent.

Conclusion: A major component of the success of the best American trauma systems lies in organisation. By contrast, many hospitals in the United Kingdom and Australasia still have no organised response to trauma and where trauma teams do exist, they are often ad hoc and disorganised. The absence of a defined team leader and precise task allocation leads to confusion and delay even when individual team members are highly skilled. We describe a trauma team approach to overcome these problems which could be utilised by any hospital using existing staff and resources.
Ectopic pregnancy with shock and negative qualitative B Human Chorionic Gonadotropin
Authors: Hertzberg Susan , Van Der Griend Michael
Published: August 2010

Objectives:

To present a case of ruptured ectopic pregnancy with hypotension, shock and a negative qualitative BhCG.

To retrospectively review patients admitted to a Sydney teaching hospital with ruptured ectopic pregnancy over a two year period.

Clinical features:

A 30 year old woman presented to the emergency department with severe abdominal pain. On arrival she was shocked, with tachycardia and hypotension. Qualitative BhCG was negative. Laparotomy revealed 2.5L of blood in the peritoneal cavity and a bleeding mass in the right fallopian tube. Pathology reported trophoblastic tissue in the wall of the tube.

Review of cases:

Of 180 patients admitted to Royal Prince Alfred Hospital with ectopic pregnancy, 37 were found to have ruptured at operation. No cases of ruptured ectopic pregnancy with a negative BhCG were found.

Conclusion:

This case, though rare, illustrates the fact that a negative serum BhCG neither excludes the diagnosis of ectopic pregnancy nor the possibility of life‐threatening tubal destruction and haemorrhage.
Adverse reactions to flumazenil in mixed drug overdose involving tricyclic antidepressants
Authors: Gray Tim
Published: August 2010

Objectives

To describe two cases of status epilepticus and major cardiac toxicity following flumazenil administration in mixed benzodiazepine and tricyclic antidepressant overdose.

To review the reported major adverse reactions to flumazenil.

To suggest guidelines for flumazenil use in the management of overdose.

Clinical features

Flumazenil was administered to two patients who were comatose following ingestion of benzodiazepines and tricyclic antidepressants. Both suffered immediate convulsions and major cardiac toxicity.

Interventions

One patient received DC defibrillation and respiratory support, the other respiratory support and cardiopulmonary bypass.

Outcomes

Both patients required admission to the Intensive Care Unit. The patient requiring cardiopulmonary bypass died of multi‐system failure, the other survived.

Conclusions

Flumazenil should not be used to reverse coma due to coingestion of benzodiazepines and tricyclic antidepressants, or undifferentiated coma in which tricyclic antidepressant intoxication may be present.
Cimetidine as an alternative to N‐acetylcysteine in patients with paracetamol poisoning
Authors: Smith Peter B , Ryan Damian
Published: August 2010

A 20 year old woman attended the emergency department of Wollongong Hospital 11 hours after a toxic ingestion of paracetamol. After developing a significant anaphylactoid reaction to N‐acetylcysteine (NAC), she was treated with cimetidine 40mg/kg intravenously as an alternative. This therapy may be an option when NAC cannot be used.
The laryngeal mask in pre‐hospital emergency care
Authors: Grantham Hugh , Phillips Garry , Gilligan J Edward
Published: August 2010

The role of the laryngeal mask airway (LMA) in pre‐hospital emergency care was studied prospectively.

Method:

Thirty ambulance officers were trained in the use of the LMA and attempted 233 insertions in the field over a 12 month period. The majority of the patients (156) had suffered cardiac arrests. The overall insertion success rate was 81%, with half the failures due to rejection of the airway by insufficiently comatose patients, and half due to other causes.

Conclusion:

The laryngeal mask offers an alternative to the Guedel airway and face mask and has some advantages.
Ovarian hyperstimulation syndrome
Authors: NIEUWKAMP G A
Published: August 2010

A 35 year old woman on the IVF program presented with ovarian hyperstimulation syndrome after induction of ovulation with human chorionic gonadotropin. This syndrome is a potentially lethal complication of ovarian stimulation with enlargement of the ovaries and transcapillary fluid shifts. This may result in third space collections in the form of ascites, hydrothorax and rarely pericardial effusions, and haemoconcentration with the attendant risks of volume depletion, renal failure and thromboembolic complications. In this patient there was also a unilateral pleural effusion and coexistent supraventricular tachycardia which has not been previously reported. The management is based on pathophysiological considerations.
CPAP apparatus: an inexpensive alternative
Authors: DINGLE KAELEEN , TAYLOR JAMES
Published: August 2010

Objective: To describe an effective and inexpensive CPAP‐mask apparatus for use in the emergency department.

Conclusion: CPAP is an effective tool in the treatment of acute pulmonary oedema in the emergency department. The mask apparatus described is an inexpensive alternative to the commercially produced machines.
Acute spontaneous subdural haematoma
Authors: Ng Man Ho
Published: August 2010

The case of a patient with acute spontaneous subdural haematoma is presented. This occurred in the absence of head injury and predisposing conditions such as bleeding diathesis, tumour, arterial aneurysm or arterio‐venous malformation. The true incidence and pathogenesis of this condition is not known. Management includes CT scanning of the head, emergency drainage of the haematoma and post‐operative angiography to rule out aneurysm or arterio‐venous malformation. Preoperative conscious level is the most important prognostic factor.
Resistance to flow through a needle‐free injection port
Authors: Holdgate Anna , Morris Richard W
Published: August 2010

Aim

To examine the effect of the Braun Reflux valve on flow rates of crystalloid and colloid solutions with different size cannulae.

Method

100ml aliquots of normal saline and Haemaccel were run through both 14 and 18 gauge cannulae from a fixed height of 1 metre. Ten measurements were made for each fluid with each cannula size then repeated with the Reflux valve interposed between the giving set and cannula for a further 10 measurements.

Results

The Reflux valve increased the resistance to flow under all conditions examined (p<0.0001). However, the actual changes in flow rates were relatively small, maximum being 12% (9.9 L/hr without valve, 8.7 L/hr with valve).

Conclusions

This study found that the valve caused a statistically significant reduction in flow rates under a variety of conditions, but the clinical significance of this reduction is important only under the most extreme circumstances. Because it has only a minor effect on resistance to flow, the authors recommend the routine use of this valve on peripheral cannulae to reduce the risk of needlestick injury and blood spillage.
Emergency department utilisation by the elderly
Authors: Lamb Ian , Eddey David , Cameron Peter
Published: August 2010

Objective

To assess the present utilisation of emergency services by the elderly in Geelong and to estimate the impact on these services of the projected increase in the elderly population.

Setting

The Geelong Hospital is a 450 bed community teaching hospital incorporating paediatric and obstetric units. It serves a population of approximately 250,000 residents covering urban and rural areas.

Methods

Analysis of computerised emergency department attendance records was undertaken covering a two year period from 1 August 1992 until 31 July 1994. Comparison with Australian Bureau of Statistics data for the region was made. For the purpose of this study “elderly” refers to 65 years and over. This group was compared with the younger population of patients including children.

Results

Of all emergency department visits 16.8% are accounted for by the 65 and over age group (Confidence interval 16.4–17.2% p<0.01). This group makes up 13% of the catchment area population. Of elderly patients attending the emergency department 59% are admitted as opposed to 19.7% of the younger group (odds ratio 3.79 Confidence interval 3.64–3.96 p<0.05). Of elderly patients admitted, 5.3% were admitted to the coronary care unit and 1.2% to the intensive care unit. This compares with 1.1% (odds ratio 5.03 Confidence interval 4.49–5.64 p<0.05) and 0.6% respectively (odds ratio 2.01 Confidence interval 1.64–2.45 p<0.05) for the younger group. The elderly patient is five times more likely to arrive by ambulance than the younger patient.

Conclusions

The elderly population are more likely to use ambulance services, more likely to attend the emergency department, more likely to require admission and more likely to require admission to a critical care area than the younger population. As the number of people over 65 increases, the consequent increase in workload will need to be addressed.
Triage nurse‐initiated X‐rays for limb injuries are accurate and efficient
Authors: Kelly Anne‐Maree , McCarthy Sandy , Richardson Sally , Parris Wendy , Kerr Anne‐Marie
Published: August 2010

Objectives

To estimate the potential reduction in waiting times for patients resulting from triage nurse‐initiated X‐rays.

To compare the pattern of X‐ray ordering by triage nurses and medical staff.

To estimate the accuracy of triage nurse‐initiated X‐rays.

Method

Prospective, blinded descriptive/comparative study with nursing intervention on an ‘intention to treat’ basis.

Results

Triage nurse‐initiated X‐rays would have identified 96% of fractures. Nurses would have ordered fewer X‐rays than doctors with an efficiency rate (number of fractures/number of X‐rays) of 41% compared with 36% for doctors. A conservative estimate of the potential time saving for patients is an average of 46 minutes.

Conclusion

Triage nurse‐initiated X‐rays should result in reduced waiting times for patients and increased efficiency of medical staff. This study suggests that this procedure would be accurate and efficient.
Intraosseous infusions through non‐styletted needles
Authors: Totten Vicken Y
Published: August 2010

This pilot study investigated the potential use of non‐styletted needles for intraosseous infusion using a cadaver model. The results suggested that, in emergency situations, fluids may be successfully infused intraosseously using non‐styletted needles.
Trauma triggered migrainous coma
Authors: Craft Philip , Kennedy Marcus P
Published: August 2010

Patients presenting in coma often present a diagnostic problem. In this case, a young man was brought by ambulance to the Nambour Hospital Emergency Department with sudden onset of coma following minor head injury. Laboratory and radiological investigations revealed no apparent cause. It was not until the patient roused spontaneously and a history of migraine was revealed that a possible aetiology was found.

Trauma precipitated migrainous coma is a diagnosis of exclusion but should be considered in the evaluation of the unconscious patient.
The emergency department management of migraine
Authors: Kelly Anne‐Maree , Bryant Michael G , Zebic Steven
Published: August 2010

Disabling migraine headache is an uncommon but important reason for presentation to emergency departments. Although not life‐threatening, migraine causes considerable distress for those affected. This article reviews the currently available parenteral agents used to treat this condition, comparing efficacy, the need for additional medication and the incidence of “rebound” headache.

Ketorolac and lignocaine fail to reach acceptable efficacy standards and are not recommended for use in acute migraine. Metoclopramide and pethidine perform a little better but each has been shown to be inferior to other treatments.

Dihydroergotamine is less effective than chlorpromazine and has a high rate of unpleasant side effects. Haloperidol needs to be studied in appropriate trials before conclusions can be drawn. The most effective agents seem to be chlorpromazine and sumatriptan, each of which has achieved greater than 70% efficacy in a number of studies. Prochlorperazine achieves this level in some studies but numbers are too small to be conclusive. Further research should concentrate on comparison of chlorpromazine, sumatriptan, prochlorperazine and haloperidol in order to clarify their relative effectiveness in the management of migraine.
The impact of assault within a regional Victorian population
Authors: Taylor David , Eddey David , Cameron Peter
Published: August 2010

The reported incidence of interpersonal violence and assault is increasing in Victoria and contributes to the rising health bill, personal grief and social disruption.

This study is a retrospective analysis of the injuries sustained by 890 assault victims presenting to the Geelong Hospital over the two year period of 1993 and 1994.

The results indicate that most injuries were relatively minor in nature and were managed in a short space of time. The head and face were injured in a high proportion of cases and few patients sustained injury as a result of stabbing or shooting. Few patients required admission to the hospital although a high proportion required follow‐up management.

The study identified the nature of physical injury suffered by the assault victims. Such knowledge is of use in the assessment of these patients in emergency departments. The study helps to elucidate the extent of this increasing yet potentially preventable social problem. The results may be used as a baseline to monitor changing patterns of assault within the region.
Venous air embolism related to the use of a pressure device for rapid blood transfusion
Authors: Hore Craig T
Published: August 2010

A 70 year old woman received a transfusion of packed red blood cells via the distal port of a subclavian central venous catheter. In order to facilitate flow, the blood pack was placed within a manually inflatable pressure bag. When the patient's oxygen saturation and systolic blood pressure fell precipitously, it was noticed that the blood pack was empty and that air was present along the entire length of the intravenous tubing. A provisional diagnosis of venous air embolism was made. Management consisted of positioning the woman head‐down in the left lateral decubitus position and ventilating with 100% oxygen. Air was unable to be aspirated from the affected central venous catheter port. Her condition improved and her subsequent intensive care unit course was uneventful.

A pulmonary artery catheter recorded haemodynamic changes at the time of the venous air embolism. There was an initial increase in pulmonary artery pressure and central venous pressure, associated with a decrease in mean arterial pressure and oxygen saturation. Similar observations have been made in animal models of graded (infusion type) venous air embolism.

The diagnosis of venous air embolism is generally clinical, aided by echocardiogram, end‐tidal carbon dioxide monitoring, pulse oximetry, chest radiography and haemodynamic monitoring. Current management of venous air embolism includes prevention of further air entry, positioning the patient head‐down in the left lateral decubitus position and administration of 100% oxygen. External cardiac massage, aspiration of air (via central venous catheter, pulmonary artery catheter or transcutaneously) and hyperbaric oxygen may also play a role.
Inter‐rater reliability of the National Triage Scale over 11,500 simulated occasions of triage
Authors: Jelinek George A , Little Mark
Published: August 2010

Since its introduction in 1993, the National Triage Scale (NTS), a five‐category scale based on the optimal time to medical intervention, has been introduced into most Australasian emergency departments as the basis of triage, clinical indicators and in some departments, casemix classification. The scale is a modification of the Ipswich Triage Scale (ITS), developed in 1989. This scale was shown in separate studies in Ipswich and Perth to be reliable and valid. The NTS however, although well validated, particularly with regard to resource use, workload and admission rates, has not been formally tested for inter‐rater reliability.

In this study the inter‐rater reliability of the NTS was assessed in eight Western Australian hospital emergency departments, covering teaching, non‐teaching, rural and private hospitals, using the same methodology and patient profiles as the original ITS study. One hundred and fifteen triage nurses in these hospitals triaged 100 written patient profiles using the NTS. Inter‐rater reliability was acceptable. Of the 115 respondents, 95% were within one category of the modal response for all but four patient profiles and 86% were within one category for all patient profiles. Concurrence, or the percentage of responses in the modal category, was good. For 89% of the profiles, more than 50% of trieurs agreed with the modal response. The distribution of modal responses was not significantly affected by hospital type or triage nurse experience. The inter‐rater reliability of the NTS overall was slightly better than for the ITS in 1989.

Emergency physicians, hospital administrators and government authorities can be confident that this widely used scale is a reliable measure of urgency.
A review of the usefulness of D‐Dimer in the diagnosis of pulmonary embolism
Authors: Mountain David , Brown Anthony FT
Published: August 2010

Pulmonary embolism is a potentially fatal condition that is extremely difficult to accurately diagnose clinically, usually relying on radiological investigations to make the diagnosis. These confirmatory tests are expensive, time consuming and may be associated with considerable morbidity. Thus, the utility of a blood test that reliably makes or refutes the diagnosis is apparent.

Most blood tests involve the later stages of thrombolysis. Of these, the D‐Dimer tests are the most sensitive, and when combined with monoclonal antibody technology, are of clinical value.

Enzyme‐linked immunosorbent assay D‐Dimer tests have good sensitivity (95%) and moderate specificity (30–45%), but technical considerations prevent their routine use. Latex agglutination tests overcome these technical problems, but their sensitivity is variable (46–100%).

Two recently introduced tests show promise. The NYCO‐CARD D‐Dimer test is a semiquantitative modified enzyme‐linked immunosorbent assay test. Relatively few clinical studies have been performed and further validation studies are required. The SimpliRED D‐Dimer test uses a new bispecific antibody technique, allows bed‐side testing, and has good sensitivity (84–100%) and negative predictive values (92–99%).

These tests could be used to screen low risk patients, thus avoiding ventilation‐perfusion scans, or in combination with ventilation‐perfusion scans and lower limb studies to avoid angiograms in intermediate probability pulmonary embolism patients. Future research will define where these tests show greatest utility, particularly in which patient subgroups, or symptom time intervals.
Lumbar puncture: risks and complications
Authors: Taylor David McD
Published: August 2010

Lumbar puncture is a procedure commonly performed in the emergency department. This paper reviews the indications, contraindications and the complications of lumbar puncture such as post‐lumbar puncture headache, traumatic tap and cerebral herniation. As well as highlighting the particular risks of lumbar puncture in different disease processes, this paper aims to provide physicians with an understanding of the procedure that will assist them in their clinical decision making. The role of computed tomography and medico‐legal aspects of lumbar puncture are also discussed.
Retropharyngeal meningioma is a rare cause of acute respiratory distress
Authors: Raftos John R , Matheson John M
Published: August 2010

A 69 year old man presented to hospital with acute respiratory distress following a fall. A retropharyngeal tumour mass was delineated by computed tomography and subsequently resected transorally. The tumour was identified as a meningotheliomatous meningioma. There was no evidence of intracranial meningioma. Extracranial meningioma is an unusual condition with the rare potential for causing respiratory insufficiency mediated by either mechanical airway obstruction or denervation.
Assault injuries in the Gold Coast region
Authors: Campbell Don , Green David
Published: August 2010

Assault is a major cause of preventable morbidity in our community. This survey of 154 victims of assault attending the Gold Coast Hospital examines the circumstances of assault injuries in the local community, and demonstrates that emergency departments have a role in gathering useful data for public health initiatives.
The identification of costs associated with emergency department attendances
Authors: Erwich‐Nijhout Marianne A , Bond Malcolm J , Phillips David G , Baggoley Chris
Published: August 2010

Aims

To calculate the cost of patient attendances to an emergency department and to identify the cost drivers of those attendances.

Setting

The Emergency Department, Flinders Medical Centre, a metropolitan teaching hospital in Adelaide, South Australia.

Methods

A prospective analysis of all attendances presenting over a five month period, incorporating detailed costings of staff and resource usage. The effects of four cost drivers were evaluated: urgency, outcome, age and diagnosis.

Results

The mean measured cost for each patient attendance was $103.79, varying from $36 for discharged category 5 patients to $429 for admitted category 1 patients. The mean total cost was $191.29, which included non‐measured and overhead components of $87.50.

Conclusion

This study identifies the costs associated with treating emergency department patients. We believe this study will be reproducible in other emergency departments. The variables that we predicted would influence the cost of clinical activities (urgency, outcome, age and diagnosis) were all found to be important determinants of the cost of emergency department attendances.
Death caused by air embolism associated with lower limb and pelvic trauma
Authors: Doley Andrew J
Published: August 2010

A 53 year old male with pelvic and lower limb injuries suffered acute cardiovascular and neurological deterioration leading to cardiac arrest. Despite aggressive resuscitation, the patient never regained a cardiac output and died of presumed massive internal injuries and hypovolaemia. Post mortem demonstrated uncomplicated rib fractures, a fractured femoral neck and a minor pelvic fracture. Death was attributed to cerebral air embolism arising from a ruptured vein in a perineal laceration.

Venous air embolism is associated with chest, head and neck trauma but is rarely seen with lower extremity and pelvic trauma. Diagnosis is difficult due to a lack of distinct diagnostic criteria and the variability in presentation. Aggressive medical and surgical management is usually unsuccessful.
Quality assurance to continuous quality improvement: development of an emergency department system
Authors: Kennedy Marcus P , Cleaton Phillip GA , Harrington Tony P , Lee Therese , McGuirk Shelley
Published: August 2010

The development of a contemporary Continuous Quality Improvement (CQT) program for an emergency department is described. The evolution of such an initiative is not complex, but requires organisational commitment and leadership.

As the focus within emergency departments becomes increasingly patient and process oriented the CQI model for quality management will become a standard managerial expectation.

We aim to present a practical description of our system which may be of use as a template for other emergency departments.
Thirty cases of Irukandji envenomation from far north Queensland
Authors: Mulcahy Richard , Little Mark
Published: August 2010

The Irukandji jelly fish (Carukia barnesi) is responsible for a significant number of envenomations in northern Australia during the summer. Emergency physicians in these coastal areas frequently manage patients who have been envenomed by this potentially serious marine creature. The jelly fish is small (its bell is up to 2.5cm across) but the tentacles may be up to half a metre in length. It is rarely seen before envenomating. The sting usually initially causes localised pain followed by systemic symptoms known as the ‘Irukandji syndrome’, which include potentially life threatening pulmonary oedema. This article discusses Irukandji envenomation and its treatment, and reviews our experience in treating 30 patients who presented to the Emergency Department of Cairns Base Hospital in December of 1996 having been stung by the Irukandji. Of these cases, 27 (90%) patients developed systemic symptoms (the Irukandji syndrome) and 19 (63%) required admission. Twelve (40%) patients required more than 100mg of titrated, intravenous pethidine to relieve the pain. There were no cases of pulmonary oedema. All patients were discharged home well within 24 hours.
A review of triage nursing practice and experience in Victorian public hospitals
Authors: Standen Pat , Dilley Stuart J
Published: August 2010

Aim

The aim of this study was to make an assessment of the way in which triage is conducted in Victoria's public hospital emergency departments, and to determine the degree of uniformity that exists in relation to staff experience, triage guidelines and physical observations recorded at triage.

Method

Nurse managers of 14 Victorian public hospital emergency departments completed surveys regarding their triage nurses' experience and triage practices.

Results

All hospitals utilised triage guidelines distributed by the Australasian College for Emergency Medicine. In addition, 10 hospitals had developed guidelines specific for the individual hospital. Four hospitals had predetermined triage categories for certain presentations. The nature and extent of physical observations recorded at triage varied widely. Triage nurse experience and training requirements also varied.

Conclusions

Training, experience and clinical aspects of the triage role vary in Victorian public hospitals. A more uniform approach to the role of triage and the training of triage nurses should be developed.
A protocol helps emergency triage nurses to request X‐rays
Authors: Wong Tai‐wai , Lee Kwong‐ming , Lau Chor‐chiu , Fu Yiu‐kai , Fung Kai‐hung
Published: August 2010

Objectives

To assess the feasibility of delegating X‐ray requests for simple limb injuries to triage nurses prior to patients being seen by a doctor, based on a protocol.

Methods

Patients with acute blunt injury to one region of a limb were included in the study. Patients who were critically ill, younger than three years, with multiple limbs injuries, or with hip or pelvis injuries were excluded. The criteria for requesting X‐ray were local bony tenderness at the site of injury plus one of the following findings: gross swelling, deformity, bruising, limitation of joint movement or inability to weight bear.

Results

A total of 934 patients were included in the study. Of these, 883 (94.54%) patients had X‐rays requested by the triage nurse. In 917 (98%) cases, nurses were judged to have adhered to the protocol. 5.44% of X‐rays requested by nurses were considered to have been unnecessary by the attending doctor. Fractures were identified in 25% of the injuries X‐rayed. Twelve (1.3%) fractures were not identified in the initial films requested by the triage nurse. The five clinical indicators used in addition to local tenderness were sensitive (98%, 95% CI 97–100%) but not specific (7%, 95% CI 5.1–8.9%) in the identification of fractures.

Conclusions

When triage nurses requested X‐rays of simple limb injuries using a protocol, this did not result in significant over‐request when compared with physicians. The protocol used was sensitive but had poor specificity.
The incidence, severity and nature of violent incidents in the emergency department
Authors: Brookes Jennifer G , Dunn Robert J
Published: August 2010

There have been few published studies investigating violent incidents occurring in the emergency department. A prospective descriptive study was undertaken over a 25 week period in two emergency departments in Melbourne, with a combined number of attendances of 56,000 patients per year. There were 79 reported violent incidents (2.8 per 1000 attendances) and staff injury occurred during nine incidents (0.3 per 1000 attendances). The frequency of incidents was highest between 1600 and 2400 hours, involved verbal violence alone in 30 (38%) incidents and physical violence in 49 (62%) incidents. In 52 (66%) incidents more than two staff members were involved. None of the possible predictors of violent behaviour studied were considered to be clinically useful in the identification of patients likely to become involved in violent incidents. Violent incidents in the emergency department place significant demands on staff and resources.
The medical consequences of a golden oldies rugby tournament
Authors: Ardagh Michael W
Published: August 2010

The 1995 International Golden Oldies Festival of Rugby attracted nearly 6000 rugby players to Christchurch for one week of rugby and socialisation. The staff of Christchurch Hospital Emergency Department were apprehensive about the likely increased demand for the department's services. This paper discusses the medical planning and the medical consequences of the tournament. This may assist medical planning for similar tournaments in the future.
Good outcomes using mask continuous positive airway pressure in elderly patients with acute pulmonary oedema
Authors: Kelly Anne‐Maree , Georgakas Con , Bau Shan , Rosengarten Pamela
Published: August 2010

Objective

To report our experience with the use of continuous positive airway pressure therapy in acute cardiogenic pulmonary oedema in patients aged 80 years and over, with particular reference to complications, intubation rates, impact on resources and quality of care.

Setting

Urban teaching hospital.

Method

Retrospective chart review of all patients aged over 80 years presenting with acute severe pulmonary oedema between 1 January and 31 December 1995.

Results

Thirty‐nine patients met the study criteria of whom 29 (75%) were treated with adjuvant mask continuous positive airway pressure. The average age of patients was 85 years. The mean duration of continuous positive airway pressure was 1.9 hours. There was one adverse event related to mask continuous positive airway pressure: one case of intolerance. All patients were managed in general medical wards after treatment in the emergency department.

Conclusion

Given the proven effectiveness of mask continuous positive airway pressure and its safety, we strongly advocate the use of continuous positive airway pressure therapy as an adjunct to standard medical therapy for patients with acute severe pulmonary oedema.
Vagal manoeuvres and drug therapy for terminating paroxysmal supraventricular tachycardias
Authors: Bonnin Robert LL , Kuhn Marie
Published: August 2010

Vagal manoeuvres are frequently used, with or without drug therapy, in the acute management of paroxysmal supraventricular tachycardia. This review provides the practical details needed to maximise the effectiveness of vagal manoeuvres and reviews the data concerning safety and relative efficacy of these techniques.

Vagal manoeuvres should be performed with the patient relaxed and supine to maximise efficacy. The valsalva manoeuvre with sphygmomanometric measurement appears to be the most effective and safest manoeuvre in adults, while the diving reflex has been demonstrated to be successful in children. Carotid sinus massage should be used with caution in the elderly as it is relatively ineffective and carries a small risk of neurological sequelae. Combining techniques to augment each other may prove useful in cases resistant to individual manoeuvres.
Undergraduate emergency medicine education in a developing country: experience from Kuala Lumpur, Malaysia
Authors: Mohamed Abdul Ali R , Aziz Azhar Abdul , Goh Emily
Published: August 2010

Of the three leading medical schools in Malaysia, the University of Malaya Medical Faculty in Kuala Lumpur is the only one currently offering a formal posting in emergency medicine. Fourth year medical students undergo two weeks of emergency department training consisting of tutorials, lectures, observation and practical sessions, bedside teaching and participation in various emergency medical activities. The structure of this teaching program at a busy teaching hospital is described in more detail. The posting is concluded with an examination consisting of an oral examination, MCQs and an essay question.

From our five years experience in conducting this program, we strongly support international recommendations for the inclusion of emergency medicine education in undergraduate medical curricula.
Integration of emergency medicine into the undergraduate medical curriculum at the Christchurch School of Medicine
Authors: Ardagh Michael
Published: August 2010

Emergency medicine has been integrated into the undergraduate curriculum of the Christchurch School of Medicine. Vertical integration has been achieved by consideration of the five stages of medical education, with the undergraduate emergency medicine contributions coming in the junior clinical student and senior clinical student stages. Horizontal integration has been achieved by defining the complete emergency medicine undergraduate curriculum and identifying those parts not adequately covered elsewhere. This paper describes how this process was achieved at the Christchurch School of Medicine.