Description

Emergency Medicine Australasia is the official journal of the Australasian College for Emergency Medicine (ACEM) and the Australasian Society for Emergency Medicine (ASEM) and aims to present papers and opinions on all aspects of emergency care in the prehospital and hospital environment. Authors are invited to submit any work that will contribute to the progress of emergency medicine within Australasia and worldwide. The Journal publishes original research articles, critical reviews, editorials, short reports, case reports, letters to the Editor and book and video reviews in the broad area of emergency medicine. Accepted papers become the copyright of the Journal. All original research articles, critical reviews and case reports are reviewed by at least two referees expert in the field of the submitted paper.

Publisher details

Blackwell Publishing

Publications in this journal

• The dilemma of paediatric drug dosing and equipment sizing in the era of patient safety.

  Authors: Ronald A Dieckmann

  Emergency medicine Australasia : EMA. 19(6):490-3.

• Effects of atmospheric temperature and humidity on outbreak of diseases.

  Authors: Sung-Hyuk Choi, Sung-Woo Lee, Yun-Sik Hong, Su-Jin Kim, Nak-Hoon Kim

  Emergency medicine Australasia : EMA. 19(6):501-8.

  OBJECTIVE: The present study aimed to determine the plausibility of forecasting the outbreak of diseases based on the weather by analysing the impact of atmospheric temperature and humidity on theOBJECTIVE: The present study aimed to determine the plausibility of forecasting the outbreak of diseases based on the weather by analysing the impact of atmospheric temperature and humidity on the occurrence of different diseases. METHODS: The subjects of the present study were the 30,434 patients who visited the ED in 1 year from 1 February 2005 to 3 February 2006. The present study analysed the correlation between the daily number of patients who suffered from 22 types of traumatic and non-traumatic diseases and the data on atmospheric temperature and humidity provided by the Korea Meteorological Administration. RESULTS: With traumatic disease, the occurrence tended to increase in proportion to the rise in temperature and humidity; whereas with non-traumatic disease, the occurrence tended to increase according to the rise in temperature, irrespective of humidity changes. The research on the impact of atmospheric temperature and humidity on different diseases revealed a high level of distribution of most diseases in an environment with high temperature and humidity. However, in the case of pulmonary diseases and trauma to multiple body regions, the occurrence increased in environments with low temperature and high humidity for pulmonary diseases, and with low temperature and low humidity for trauma to multiple body regions. CONCLUSION: Most diseases tend to increase in proportion to the rise in atmospheric temperature whereas being less affected by humidity. However, an increase in humidity in an optimum range of atmospheric temperature (12 degrees C or higher) triggers an increase in the occurrence of diseases.

• Use of information technology in New Zealand emergency departments.

  Authors: Eunicia Tan, Kim M Yates

  Emergency medicine Australasia : EMA. 19(6):515-22.

  OBJECTIVES: To determine previous computer training and current computer confidence of emergency medicine (EM) specialists and trainees, and to determine the accessibility of computer and InternetOBJECTIVES: To determine previous computer training and current computer confidence of emergency medicine (EM) specialists and trainees, and to determine the accessibility of computer and Internet resources in New Zealand ED. METHODS: A prospective, cross-sectional study of all New Zealand EM specialists and trainees between July 2005 and October 2005, using a 47-item postal questionnaire. Descriptive statistics with 95% confidence intervals were compiled. Fisher's exact test was used to compare proportions, with t-test and Mann-Whitney U-test to compare continuous variables. RESULTS: A total of 226 EM specialists and trainees were sent questionnaires. In total, 144 (62 specialists and 82 trainees) out of 224 were analysed (response rate 64.3%). The majority of respondents (136, 94.4% (95% CI 89.4-97.6)) had access to a computer at home. Almost all respondents (143, 99.3% (95% CI 96.2-100.0)) also had computer access in the ED 24 h/day. The vast majority (140, 97.2% (95% CI 93.0-99.2)) had access to medical educational materials via the Internet in the ED 24 h/day. Most respondents had limited prior computer training. Respondents felt most confident using word processing and e-mail/communications applications, and least confident using statistical and graphics programs. Compared with specialists, trainees were significantly less confident with spreadsheets (P = 0.002), literature searching (P = 0.034), and e-mail/communications (P = 0.040). CONCLUSIONS: Increased access to computer technology has not been parallelled by increased confidence in the use of computers among EM specialists and trainees. Training must address gaps in computer literacy if computer technology is to be used to its full potential.

• External validation of the Best Guess formulae for paediatric weight estimation.

  Authors: Anne-Maree Kelly, Debra Kerr, Megan Clooney, David Krieser, Kevin Nguyen

  Emergency medicine Australasia : EMA. 19(6):543-6.

  OBJECTIVE: A new method for estimation of weight in children based on their age has been proposed. The present study aims to validate the Best Guess formulae in a new population of children. METHODS:OBJECTIVE: A new method for estimation of weight in children based on their age has been proposed. The present study aims to validate the Best Guess formulae in a new population of children. METHODS: This was a secondary analysis of a database collected for a prospective, observational, cohort study conducted in the Paediatric ED of Sunshine Hospital. Children aged 1-11 years who presented to the ED between 18 August 2005 and 25 February 2006 were included. Actual weight, height, age and ethnicity were obtained. Agreement between estimated weight using the Best Guess formulae and measured weight is reported using mean bias, 95% limits of agreement and proportion within 20% of actual weight. RESULTS: A total of 410 cases were included in the present study. Forty-six per cent were female and median age was 4 years. The mean bias in the 1-5 year group was 0.9 kg, with 95% limits of agreement -3.5 to +5.3 kg. Seventy-six per cent of estimations were within 20% of measured weight. The mean bias in the 5-11 year group was 0.4 kg, with 95% limits of agreement -14.4 to +15.2 kg. In this group, 64% of estimations were within 20% of measured weight. CONCLUSION: The Best Guess formulae performed moderately well in estimating children's weight, but had a tendency to overestimate weight, particularly in children with lower body mass index.

• Meningococcal meningitis and a negative cerebrospinal fluid: case report and its medicolegal implications.

  Authors: William Huynh, Rajat Lahoria, Roy G Beran, Dennis Cordato

  Emergency medicine Australasia : EMA. 19(6):553-5.

  A normal result on the initial cerebrospinal fluid (CSF) study has been traditionally used to exclude the potential diagnosis of bacterial meningitis. However, there have been a number of caseA normal result on the initial cerebrospinal fluid (CSF) study has been traditionally used to exclude the potential diagnosis of bacterial meningitis. However, there have been a number of case studies of bacterial meningitis confirmed by CSF culture, in which an initial lumbar puncture yielded completely normal parameters. A review of the literature reports the frequency of this scenario to arise in 0.5% to 12% of cases. This might result in the delay of appropriate treatment for this potentially fatal condition. We report a 21-year-old female patient who presented with a clinical picture compatible with bacterial meningitis but with a normal initial CSF result. Neisseria meningitidis was later cultured from her CSF. The medicolegal aspects surrounding such a scenario, and its implications towards clinical practice are discussed. We conclude that an abnormal initial CSF study might indicate a diagnosis of bacterial meningitis but a normal result does not exclude it and should not delay early institution of appropriate antimicrobial therapy.

• Adenosine-induced complete heart block: not so transient.

  Authors: Martyn G Harvey, Shameem Safih, Muir Wallace

  Emergency medicine Australasia : EMA. 19(6):559-62.

  Adenosine is a purine nucleoside widely used to terminate supraventricular tachycardias, and as a diagnostic adjunct in narrow complex regular tachycardia of uncertain origin. AtrioventricularAdenosine is a purine nucleoside widely used to terminate supraventricular tachycardias, and as a diagnostic adjunct in narrow complex regular tachycardia of uncertain origin. Atrioventricular blockade and bradyarrhythmias following administration are common but generally short-lived. We report a case of prolonged complete heart block requiring intubation and temporary pacing, following adenosine administration in atrial flutter treated with combination metoprolol and diltiazem.

• Emergency Medicine Australasia: progress and prospects.

  Authors: Anthony F T Brown

  Emergency medicine Australasia : EMA. 19(6):487-9.

• Trauma team radiation exposure: the potential need for dosimetry monitoring.

  Authors: Mana Ittimani, Gary Goozée, Alvaro Manovel, Anna Holdgate

  Emergency medicine Australasia : EMA. 19(6):494-500.

  OBJECTIVES: Australian radiation regulations require routine monitoring of health-care workers who might receive a whole-body effective radiation dose in excess of 1 mSv/year. In AustralianOBJECTIVES: Australian radiation regulations require routine monitoring of health-care workers who might receive a whole-body effective radiation dose in excess of 1 mSv/year. In Australian hospitals, routine monitoring with a dosimeter is recommended for levels beyond 300 microSv/year. We aimed to determine the potential radiation exposure to trauma team members and whether routine personal radiation dosimetry should be recommended. METHOD: An anthropomorphic mannequin with a radiation detector was placed at five locations around the resuscitation bed. Three sets of standard trauma-series X-rays were performed, and the exposure was measured and averaged at each location. These data were then extrapolated to estimate the potential radiation equivalence at the level of the thyroid gland for staff working in each of the locations over a 1 year period with and without personal protective equipment. RESULTS: The total dose ranged from 1.2 to 20.5 microSv for a single trauma patient. The highest recorded dose was at the location of the circulation doctor during pelvic X-ray. Based on these data, it would take only 15 trauma patients per year for a team member to be potentially exposed to the level at which routine dosimetry is usually recommended, should no personal protective equipment be used. The use of a lead gown and a lead gown with a thyroid collar reduced exposure by four- and ninefold, respectively. CONCLUSIONS: We have demonstrated the possibility of significant ionizing radiation exposure for unprotected trauma team members. Dosimeter use by trauma team personnel needs to be reviewed based on local protocols and patient numbers.

• Current status of Japanese emergency medicine based on a cross-sectional survey of one prefecture.

  Authors: Takahiro Ezaki, Tomomi Yamada, Mitsuhiro Yasuda, Tomoo Kannna, Kiminori Shiraishi, Makoto Hashizume

  Emergency medicine Australasia : EMA. 19(6):523-7.

  OBJECTIVE: To ascertain the current status of emergency medicine at certified emergency hospitals in Fukuoka, a Japanese prefecture. Fukuoka prefecture has the 9th largest population volume of the 46OBJECTIVE: To ascertain the current status of emergency medicine at certified emergency hospitals in Fukuoka, a Japanese prefecture. Fukuoka prefecture has the 9th largest population volume of the 46 prefectures throughout Japan. METHODS: Written questionnaire sent to 146 certified emergency hospitals. RESULTS: A total of 132 of 146 (90.4%) emergency hospitals replied. Data were complete from 131. Nineteen of 131 hospitals (14.5%) were qualified by the Japanese Association for Acute Medicine, whereas 85 of 131 (64.9%) were certified by other medical associations. In 32 of 131 hospitals (24.4%), there was an emergency medicine specialist or acute care physician, whereas 117 hospitals (89.3%) had a specialist doctor qualified by another medical association. In 33 of 131 hospitals (25%), there were doctors who undertook training in emergency medicine of surgery-related courses, and 66 (50%) undertook internal medicine-related courses. CONCLUSION: The current status of emergency medicine practice in the Fukuoka prefecture is poor. Medical associations relevant to emergency medicine should collaborate with each other to share information, as well as provide help to solve problems associated with emergency medicine manpower. This collaboration should occur as a national effort within the Japanese Association for Acute Medicine.

• Use of point-of-care ultrasound by a critical care retrieval team.

  Authors: Stefan M Mazur, Andrew Pearce, Sam Alfred, Peter Sharley

  Emergency medicine Australasia : EMA. 19(6):547-52.

  Point-of-care ultrasound in the prehospital and retrieval environments has now become possible owing to decreased size and weight, and increasing robustness of some ultrasound machines. This reportPoint-of-care ultrasound in the prehospital and retrieval environments has now become possible owing to decreased size and weight, and increasing robustness of some ultrasound machines. This report describes the initial experience of point-of-care ultrasound by an Australian critical care retrieval service using a portable ultrasound machine.

• Deliberate self-poisoning with tiagabine: an unusual toxidrome.

  Authors: Richard A Forbes, Harish Kalra, L Peter Hackett, Frank F S Daly

  Emergency medicine Australasia : EMA. 19(6):556-8.

  Tiagabine is an anticonvulsant acting by selective inhibition of neuronal and glial gamma-aminobutyric acid uptake, resulting in increased gamma-aminobutyric acid-mediated inhibition in the brain.Tiagabine is an anticonvulsant acting by selective inhibition of neuronal and glial gamma-aminobutyric acid uptake, resulting in increased gamma-aminobutyric acid-mediated inhibition in the brain. Few reports in the literature describe the clinical course of severe tiagabine intoxication. A 44-year-old woman presented after deliberate self-poisoning with 100 tiagabine 15 mg tablets (1,500 mg; 25 mg/kg). Serum tiagabine level was 4,600 microg/L (1,725 mmol/L) at presentation, 20 times levels associated with therapeutic dosing. Intoxication was manifested by profuse vomiting, coma, myoclonus, generalized rigidity, bradycardia, hypertension, hypersalivation and generalized piloerection within 2 h of ingestion. The patient was intubated and management was supportive. Coma lasted until 10 h post-ingestion, but recovery was complicated by severe agitated delirium lasting 12 h. The patient recovered fully within 26 h of ingestion. Tiagabine deliberate self-poisoning was associated with the rapid onset of coma and an unusual toxidrome. Recovery, although complicated by agitated delirium, was complete within 26 h.

• Thinking outside the box.

  Authors: Randall Greenberg, Stephen Peak, Alex Browne

  Emergency medicine Australasia : EMA. 19(6):563.

• Make your Best Guess: an updated method for paediatric weight estimation in emergencies.

  Authors: Katie Tinning, Jason Acworth

  Emergency medicine Australasia : EMA. 19(6):528-34.

  BACKGROUND: For children requiring weight-based resuscitative measures, it is often difficult to obtain an accurate weight. In these cases, it is common practice to estimate the weight based on age.BACKGROUND: For children requiring weight-based resuscitative measures, it is often difficult to obtain an accurate weight. In these cases, it is common practice to estimate the weight based on age. As the average weight of Australian children has increased over the last two decades, the widely used advanced paediatric life support (APLS) method might systematically underestimate weight in paediatric patients. OBJECTIVE: To devise a simple age-based method for estimating weight that is more accurate than the APLS method. METHODS: A retrospective observational study of all patients (aged 0-14 years) presenting to a tertiary paediatric ED over a 3 year period was performed. Presentations were divided into infants (<12 months), preschool-aged (1-4 years) and school-aged children (5-14 years). Weight measurements performed at triage were recorded and regression analysis performed to produce equations describing the relationship between weight and age for each group. RESULTS: There were 70,181 presentations suitable for inclusion in the present study. Mean weight for age (+/-2 SD) is presented in tabular form. Three simplified linear equations were derived to calculate mean weight for age. For Infants < 12 months: Weight (kg) = (age in months + 9)/2 For Children aged 1-5 years: Weight (kg) = 2 x (age in years + 5) For Children aged 5-14 years: Weight (kg) = 4 x age in years. CONCLUSION: The present study devised an age-based method for paediatric weight estimation which should more accurately predict weight than the widely used APLS formula.

• Prehospital analgesia in adults using inhaled methoxyflurane.

  Authors: Paul Buntine, Ogilvie Thom, Franz Babl, Michael Bailey, Stephen Bernard

  Emergency medicine Australasia : EMA. 19(6):509-14.

  OBJECTIVE: For many years, ambulance services throughout Australia have been administering methoxyflurane as a first-line analgesic agent. However, there is a paucity of literature regarding itsOBJECTIVE: For many years, ambulance services throughout Australia have been administering methoxyflurane as a first-line analgesic agent. However, there is a paucity of literature regarding its efficacy, safety and usage profile. The present study was designed to examine the efficacy of methoxyflurane in adults. METHODS: An observational case series was conducted over a 10 month period. Adults to whom methoxyflurane was administered while traveling by ambulance to an urban teaching hospital were enrolled. Data analysed included indications for use, verbal numerical pain scores, depth of sedation and adverse effects. Data were collected via paramedic, patient and ED staff surveys. RESULTS: Eighty-three adult patients were enrolled over a 10 month period. A mean reduction in verbal numerical rating scale (VNRS) scores of 2.47 +/- 0.24 (on a 10-point scale) was recorded 5 min post methoxyflurane, with a total reduction of 3.21 +/- 0.24 at time of arrival at the ED. Both VNRS scores were significantly different from baseline (P < 0.0001). Fifteen patients (18.1%, 95% CI 9.8-26.4%) reported mild side-effects either during or shortly after administration. A total of 68 (81.9%, 95% CI 72.0-89.5%) of the paramedics and 60 (72.3%, 95% CI 61.4-81.6%) of the patients interviewed said that they felt satisfied with the level of analgesia provided by methoxyflurane. CONCLUSION: The use of methoxyflurane as a prehospital analgesic significantly reduced pain in patients, with no significant side-effects attributed to its use. The majority of patients and paramedics interviewed were satisfied with its effects and indicated a willingness to use it again.

• Best Guess method for age-based weight estimation in paediatric emergencies: validation and comparison with current methods.

  Authors: Michelle T Thompson, Michael J Reading, Jason P Acworth

  Emergency medicine Australasia : EMA. 19(6):535-42.

  BACKGROUND: During paediatric resuscitation, drug doses are calculated based upon weight. Age-based weight estimates are used when weighing children is impractical. The average weight of AustralianBACKGROUND: During paediatric resuscitation, drug doses are calculated based upon weight. Age-based weight estimates are used when weighing children is impractical. The average weight of Australian children has increased, and widely used paediatric age-based formulae might underestimate weight. A modified age-based method for paediatric weight calculation, the 'Best Guess', has been described. OBJECTIVE: To validate the Best Guess formulae on a new population of paediatric emergency patients, and to compare the accuracy of this method with Advanced Paediatric Life Support (APLS) and Australian Resuscitation Council (ARC) formulae for age-based weight calculations. METHODS: A retrospective study was performed of Australasian Triage Scale (ATS) category 1 or 2 patients presenting to a tertiary paediatric ED over a 12 month period. Calculated weights using each method (APLS, ARC and Best Guess) were compared with true weights for infants (<1 year), preschool-aged (1-4 years) and school-aged (5-14 years) children. Mean actual error and mean percentage error for each was calculated. RESULTS: A total of 1843 patient weights were included in the study. The Best Guess Infant formula accurately estimated weight (mean percentage error +4.2%). The Best Guess formulae more accurately estimated weight than both APLS and ARC formulae for both preschool-aged children (mean percentage error +2.6% vs-12.1% vs-12.1%) and school-aged children (mean percentage error +7.7% vs-19.9% vs-12.4%). CONCLUSION: The Best Guess formulae is a valid method for age-based weight estimation in acutely unwell or injured children presenting to the ED and more accurately predicts mean weight than either APLS or ARC formulae.

• Propofol in emergency medicine: further evidence of safety.

  Authors: Steven M Green

  Emergency medicine Australasia : EMA. 19(5):389-93.

• Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation.

  Authors: Anthony Bell, Greg Treston, Charley McNabb, Kathy Monypenny, Robert Cardwell

  Emergency medicine Australasia : EMA. 19(5):405-10.

  OBJECTIVES: To evaluate the rate of adverse respiratory events and vomiting among ED patients undergoing procedural sedation with propofol. METHODS: This was a prospective, observational series ofOBJECTIVES: To evaluate the rate of adverse respiratory events and vomiting among ED patients undergoing procedural sedation with propofol. METHODS: This was a prospective, observational series of patients undergoing procedural sedation. Titrated i.v. propofol was administered via protocol. Fasting status was recorded. RESULTS: Four hundred patients undergoing sedation were enrolled. Of these 282 (70%, 95% confidence interval [CI] 66-75%) had eaten or drunken within 6 and 2 h, respectively. Median fasting times from a full meal, snack or drink were 7 h (interquartile range [IQR] 5-9 h), 6 h (IQR 4-8 h) and 4 h (IQR 2-6 h), respectively. Overall a respiratory event occurred in 86 patients (22%, 95% CI 18-26%). An airway intervention occurred in 123 patients (31%, 95% CI 26-35%). In 111 cases (90%, 95% CI 60-98%) basic airway manoeuvres were all that was required. No patients were intubated. Two patients vomited (0.5%, 95% CI 0.0-1.6%), one during sedation, one after patient became conversational. One patient developed transient laryngospasm (0.25%, 95% CI 0-1.2%) unrelated to vomiting. There were nil aspiration events (0%, 95% CI 0-0.74%). CONCLUSIONS: Seventy per cent of patients undergoing ED procedural sedation are not fasted. No patient had a clinically evident adverse outcome. Transient respiratory events occur but can be managed with basic airway interventions making propofol a safe alternative for emergency physicians to provide emergent procedural sedation.

• Management and outcome of spontaneous pneumothoraces at three urban EDs.

  Authors: Richard Paoloni

  Emergency medicine Australasia : EMA. 19(5):449-57.

  OBJECTIVE: Spontaneous pneumothoraces predominantly affect young people. Substantial morbidity arises from the disease, invasive procedures and hospitalization. The literature is inconsistentOBJECTIVE: Spontaneous pneumothoraces predominantly affect young people. Substantial morbidity arises from the disease, invasive procedures and hospitalization. The literature is inconsistent regarding optimal management. This retrospective study aimed to define factors affecting the outcome of these patients. METHODS: Patients were identified from databases at three EDs for explicit retrospective medical record review. Iatrogenic and traumatic pneumothoraces were excluded. Data collected included demographic details, treatment and outcome. The primary outcome was failure of initial treatment, defined as the need for a second treatment modality (including inpatient pleurodesis for persistent air leak) or re-presentation within 5 days of treatment cessation. Associations with the primary outcome in primary spontaneous pneumothorax were assessed using logistic regression. RESULTS: One hundred and twenty-one spontaneous pneumothoraces were identified. There was poor correlation between clinician estimates and objective measurement of pneumothorax size. Pneumothorax size, measured using the average interpleural distance method, was the only independent predictor of treatment failure. Initial treatment modality demonstrated a confounder relationship with outcome. Subgroup analysis for patients treated with continuous pleural drainage compared small and large calibre drainage tubes, with no significant difference found. CONCLUSIONS: Objective measurement of pneumothorax size was the only independent predictor of treatment failure, with initial treatment modality having a confounding effect. Algorithms regarding initial treatment modalities are usually based on pneumothorax size and presence or absence of symptoms. The present study illustrates the importance of objective assessment of pneumothorax size in both clinical research and clinical practice.

• Investigation of the rate of meningitis in association with urinary tract infection in infants 90 days of age or younger.

  Authors: Peter J Vuillermin, Mike Starr

  Emergency medicine Australasia : EMA. 19(5):464-9.

  OBJECTIVE: To test the hypothesis that urinary tract infections (UTI) in young infants are rarely associated with meningitis. METHODS: We undertook a review of the laboratory results from 322OBJECTIVE: To test the hypothesis that urinary tract infections (UTI) in young infants are rarely associated with meningitis. METHODS: We undertook a review of the laboratory results from 322 infants, 90 days of age or younger, with an admission or discharge diagnosis of UTI or meningitis. The study was conducted in a tertiary paediatric hospital. The primary outcome measure was the incidence of coexisting urinary tract and cerebrospinal fluid sepsis. RESULTS: In total, 161 of the 322 (50%) infants with an admission or discharge diagnosis of UTI or meningitis were subsequently shown to have a culture-proven UTI. Of the children with a culture-proven UTI, 75 (47%) had cerebrospinal fluid obtained. We detected one case of probable bacterial meningitis in association with UTI. CONCLUSION: UTI is rarely associated with meningitis in infants 90 days of age or younger.

• Stephen's Banded Snake envenomation treated with tiger snake antivenom.

  Authors: Michael Hession

  Emergency medicine Australasia : EMA. 19(5):476-8.

  Demonstration of the use of Tiger Snake Anti-venom in Stephen's Banded Snake envenomation is described. The patient presented with a clear history of a bite and a mild headache. Subsequently, theDemonstration of the use of Tiger Snake Anti-venom in Stephen's Banded Snake envenomation is described. The patient presented with a clear history of a bite and a mild headache. Subsequently, the patient developed defibrination coagulopathy. A swab of the bite site reacted to the Tiger Snake Antivenom Indicated Well 1 [corrected] on the Commonwealth Serum Laboratories Snake Venom Detection Kit [corrected] Two ampoules of anti-venom were used. A mild allergic reaction to tiger snake antivenom developed. There was resolution of the coagulopathy.

• Magnesium sulphate for phaeochromocytoma crisis.

  Authors: Adam Morton

  Emergency medicine Australasia : EMA. 19(5):482.

• Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool?

  Authors: Amanda Saracino

  Emergency medicine Australasia : EMA. 19(5):394-404.

  Acute shortness of breath is a potential marker of serious cardiopulmonary disease and requires rapid assessment. In our current health-care system, increasing pressure on the ED to limit costs andAcute shortness of breath is a potential marker of serious cardiopulmonary disease and requires rapid assessment. In our current health-care system, increasing pressure on the ED to limit costs and waiting times has resulted in the development of many clinical decision aids and admission prediction tools designed to assist ED physicians in meeting these demands. However, most of these tools are disease specific, and none are currently available for application to patients presenting to the ED with shortness of breath. Although somewhat limited, current evidence supports the utilization of a simple dyspnoea rating scale, to assist in the streamlining of clinical severity assessments and urgency evaluations, and to potentially provide useful information to facilitate rapid and accurate site-of-care decisions in this setting.

• Route of administration of redback spider bite antivenom: determining clinician beliefs to facilitate Bayesian analysis of a clinical trial.

  Authors: Simon G A Brown, Geoffrey K Isbister, Barrie Stokes

  Emergency medicine Australasia : EMA. 19(5):458-63.

  OBJECTIVE: To determine current beliefs of Australasian emergency physicians, to form the basis of 'stopping rules' for a clinical trial of intravenous (i.v.) versus intramuscular (i.m.) redbackOBJECTIVE: To determine current beliefs of Australasian emergency physicians, to form the basis of 'stopping rules' for a clinical trial of intravenous (i.v.) versus intramuscular (i.m.) redback spider antivenom. METHODS: An email survey of fellows and trainees of the Australasian College for Emergency Medicine. RESULTS: There were 218 responses; 30% used the i.v. route exclusively, 16% used the i.m route exclusively, 17% used i.m. followed by i.v. if there was a poor initial clinical response, and 38% stated that they had no particular preference. The probability given by respondents that the i.v. route is superior allowed us to differentiate 'i.v. enthusiasts' from 'i.v. sceptics'. Median predicted response rates were 90% versus 80% for the i.v. route and 60% versus 75% for the i.m. route in the enthusiastic and sceptical groups, respectively. The median expected absolute advantage of i.v. compared with i.m. antivenom was 20% versus 5%, respectively. The median number-needed-to-treat threshold that would lead respondents to choose the i.v. route in preference to the i.m. was 5. CONCLUSION: Australasian emergency physicians have polarized views on the optimal route for administering redback spider antivenom. We were therefore able to define both sceptical and enthusiastic priors for a fully Bayesian trial analysis. Our findings support using a number needed to treat of 5 (20% absolute advantage) for powering a clinical study and for determining the point at which it should be stopped.

• Emergency medicine in a developing country: experience from Kilimanjaro Christian Medical Centre, Tanzania, East Africa.

  Authors: Megan Cox, John Shao

  Emergency medicine Australasia : EMA. 19(5):470-5.

  Tanzania in East Africa has a population of over 36 million and is one of the poorest countries in the world. Life expectancy has declined and infant mortality rates are increasing. Four consultantTanzania in East Africa has a population of over 36 million and is one of the poorest countries in the world. Life expectancy has declined and infant mortality rates are increasing. Four consultant specialist hospitals and 17 regional hospitals service the mainland. Kilimanjaro Christian Medical Centre is a major specialist teaching hospital with 500 beds, serving the entire north-west of the country. There is a small 'casualty' ward with three cubicles and one resuscitation room. Malaria, HIV, respiratory infections and gastroenteritis are the chief causes of death in children. Changing lifestyle and Western influences have increased diabetes and vascular disease in adults, and large numbers of trauma deaths are increasingly encountered. Kilimanjaro Christian Medical Centre 'Casualty' admission data are presented, as well as an insight into the challenges of emergency medicine in this country.

• Air bag-associated burn.

  Authors: Vivek K Sinha, Kirstie A MacGill

  Emergency medicine Australasia : EMA. 19(5):479-81.

  Burns due to the deployment of air bags have been occasionally described in recent years. Most reports are about injuries in the USA. However, there have been few reports of this type of injury inBurns due to the deployment of air bags have been occasionally described in recent years. Most reports are about injuries in the USA. However, there have been few reports of this type of injury in Australia. This case report details such an injury that took place in a road traffic accident in Melbourne, Australia.

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