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Reade, Michael C; Davies, Suzanne R; Morley, Peter T; Dennett, Jennifer; Jacobs, Ian C; Jacobs, Ian C
doi: 10.1111/j.1742-6723.2012.01538.xpmid: 22672162
Cyanide poisoning is uncommon, but generates interest because of the presumed utility of an antidote immediately available in those areas with a high risk of cyanide exposure. As part of its regular review of guidelines, the Australian Resuscitation Council conducted a systematic review of the human evidence for the use of various proposed cyanide antidotes, and a narrative review of the relevant pharmacological and animal studies. There have been no relevant comparative or placebo‐controlled human trials. Nine case series were identified. Treatment with hydroxocobalamin was reported in a total of 361 cases. No serious adverse effects of hydroxocobalamin were reported, and many patients with otherwise presumably fatal poisoning survived. Sodium thiosulphate use was reported in two case series, similarly with no adverse effects. Treatment with a combination of sodium nitrite, amyl nitrite and sodium thiosulphate was reported in 74 patients, with results indistinguishable from those of hydroxocobalamin and sodium thiosulphate. No case series using dicobalt edetate or 4‐dimethylaminophenol were identified, but successful use in single cases has been reported. Hydroxocobalamin and sodium thiosulphate differ from alternatives in having negligible adverse effects, and on the basis of current evidence are the antidotes of choice. The indications for the use of an antidote, the requirements for supportive care and a recommended approach for workplaces where there is a risk of cyanide poisoning are presented.
Saad Aldin, Ehab; Saadeh, Joanna; Ghulmiyyah, Labib; Hitti, Eveline
doi: 10.1111/j.1742-6723.2012.01543.xpmid: 22672163
Ectopic pregnancy after hysterectomy is a rare but potentially life‐threatening condition requiring prompt diagnosis to prevent the increased mortality associated with rupture. Twenty‐seven cases of late post‐hysterectomy ectopic pregnancy reported in the English literature since 1918 were reviewed and analysed for presenting symptoms, missed diagnosis rate at initial presentation, location of ectopic and rupture rate at diagnosis. The presenting symptoms were found to be non‐specific. The diagnosis in this population is twice more likely to be missed than in women with intact uteri. The rupture rate is 63%, compared with 37% in women with intact uteri. The majority of late post‐hysterectomy ectopic pregnancies (62%) were located in the fallopian tubes. Because of the potential risk of mortality, emergency physicians should always consider the possibility of ectopic pregnancy in childbearing women whose surgical history includes hysterectomy without oophorectomy. Evaluation of abdominal pain in this population should include a pregnancy test to ensure prompt diagnosis when the possibility of pregnancy exists clinically.
Jelinek, George A; Marck, Claudia H; Weiland, Tracey J; Neate, Sandra L; Hickey, Bernadette B
doi: 10.1111/j.1742-6723.2012.01535.xpmid: 22672164
Objective: The ED is emerging as a priority for efforts to improve rates of organ and tissue donation (OTD) in Australia, but little is known of ED clinicians' attitudes, education or practices in the area. We aimed to determine the attitudes and OTD‐related educational background and practices of Australian ED clinicians. Methods: This was a national cross‐sectional survey of members of the Australasian College for Emergency Medicine (ACEM) and the College of Emergency Nursing Australasia (CENA); online questionnaire of 133 items, graded responses using Likert and ordinal multi‐category scales, plus open‐ended qualitative questions. Results: Of 2969 ACEM members, 599 (20.2%) responded; of 1026 CENA members, 212 (20.7%) responded. Respondents were broadly representative of the membership, with male trainee specialists underrepresented. Most ED staff supported OTD, although many were not certain that facilitating OTD was their role, or that the ED was the right place to identify donors. Around a quarter of medical and nursing staff had received no education regarding OTD. Having received education was related to professional status, cultural background, place of work and years of experience, and was significantly associated with attitude towards OTD and whether staff participated in OTD‐related tasks. Conclusions: More education on OTD is needed and requested by ED clinicians in Australia, particularly on OTD after cardiac death, management of a donor, brain death and obtaining consent. Postgraduate curricula should reflect this need for more OTD‐related education in emergency medicine and nursing.
Haire, Julia Christine Lydia; Ferguson, Sally Anne; Tilleard, James D; Negus, Paul; Dorrian, Jillian; Thomas, Matthew JW
doi: 10.1111/j.1742-6723.2012.01533.xpmid: 22672165
Objective: To evaluate the effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and psychomotor performance in a group of Australian emergency registrars. Methods: A prospective observational study with a repeated within‐subjects component was conducted. Sleep time was determined using sleep diaries and activity monitors. Subjective fatigue levels and reciprocal reaction times were evaluated before and after day and night shifts. Results: A total of 11 registrars participated in the study with 120 shifts analysed. Sleep time was found to be similar during consecutive night and day shifts. The mean number of hours spent awake before the end of a night shift was 14.33. Subjective fatigue scores were worst at the end of a night shift. There was no difference in reciprocal reaction time between the end of night shift and the start of day shift. Conclusions: Registrars sleep a similar amount of time surrounding night and day shifts. Despite reporting the highest levels of fatigue at the end of a night shift, there is no significant difference in reaction times at the end of night shift compared with the beginning of day shift. This correlates with the finding that at the end of night shift the registrars have been awake for less than 16 h, which is the point at which psychomotor performance is expected to decline.
doi: 10.1111/j.1742-6723.2012.01536.xpmid: 22672166
Objective: To investigate the prognostic utility of Heart Foundation (Australia) risk stratification table in an ED chest pain population. Methods: A planned sub‐study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome (ACS) was conducted. Data collected included demographical, clinical, ECG, biomarker and outcome data. Outcome of interest was diagnostic utility of the classification system for ACS or myocardial infarction (MI) at index presentation and major adverse cardiac events (MACE) within 7 and 30 days. MACE included death, cardiac arrest, revascularization, cardiogenic shock, arrhythmia and prevalent (cause of presentation) and incident (occurring within the follow‐up period) MI. Analysis was by descriptive and receiver–operator curve analyses. Results: Seven hundred and sixty‐eight patients were studied; 109 had MI (14.2%, 95% confidence interval (CI) 11.9–16.8%). There were 88 MACE at 7 days (13.5%, 95% CI 11.1–16.4%) and 93 MACE at 30 days (14.4%%, 95% CI 11.9–17.3%). Diagnostic performance (c‐statistic) of the National Heart Foundation risk classification for ACS, MI, 7 and 30 day MACE was 0.74 for each (95% CI 0.71–0.77). Although sensitivity of the high‐risk classification for MI, 7 and 30 day MACE was high (99–100%), specificity was low (48–50%). Conclusion: The Heart Foundation risk classification shows only fair predictive performance for MI, 7 and 30 day MACE. With specificity of approximately 50%, the recommendation for coronary care admission for all high‐risk patients is hard to justify.
Havard, Alys; Shakeshaft, Anthony P; Conigrave, Katherine M
doi: 10.1111/j.1742-6723.2012.01537.xpmid: 22672167
Objective: This study measures the prevalence of problematic alcohol consumption in patients of EDs in rural areas of Australia, relative to the general population in the same rural communities. It also identifies the characteristics associated with risky drinking in rural ED patients. Methods: Surveys containing the Alcohol Use Disorders Identification Test (AUDIT) and questions corresponding to the 2001 Australian Alcohol Guidelines were completed by 1056 patients presenting to five EDs in rural areas of New South Wales, and 756 residents of the same five communities. Results: Relative to the general community, ED patients were statistically significantly more likely to engage in risky alcohol consumption according to the AUDIT (39% vs 20%), alcohol consumption posing a high risk of short‐term harm (26% vs 18%) and alcohol consumption posing a high risk of long‐term harm (7% vs 3%). Although being aged under 40 years of age, being unmarried, not completing school and being assigned less urgent triage categories were associated with risky alcohol use among ED patients, rates of risky consumption were high across all patient subgroups. Conclusions: Risky drinking, across a number of measures, is overrepresented in patients of rural Australian EDs relative to the general community, and this type of consumption is not limited to certain subgroups of patients. There is a need for interventions that address both heavy single occasion drinking and excessive regular consumption in patients of rural Australian EDs, with universal interventions recommended rather than targeted programmes.
Meek, Robert; Tong, Roger Lien‐Kien
doi: 10.1111/j.1742-6723.2012.01539.xpmid: 22672168
Objectives: To determine the incidence and risk factors for symptomatic venous thromboembolism (VTE) in adults who are discharged from the ED with rigid immobilization for lower limb injury. Methods: Eligible patients presenting between 1 December 2008 and 31 December 2010 were identified retrospectively from the Southern Health ED (Monash Medical Centre, Dandenong Hospital, Casey Hospital, all located in Melbourne, Australia) information system. Age, sex, diagnosis, type of splint and other defined potential VTE risk factors were recorded. VTE was confirmed from archived diagnostic imaging or hospital re‐attendance records. Patients presenting between 1 October 2010 and 31 December 2010 were contacted to detect VTE diagnosed and treated outside of Southern Health. VTE incidence is reported, and comparison of risk factors performed. Results: VTE was initially confirmed in 33 of 1231 patients (2.7%, 95% confidence interval 1.9–3.7). VTE was reported by 3 of 174 in the contacted subgroup (1.7%, 0.4–4.6). Applying this ‘missed rate’ to the whole sample, the estimated VTE incidence is between 3.1% and 7.1%. Multivariate risk factor analysis found VTE risk to increase with age and a diagnosis of Achilles tendon rupture. Conclusion: The estimated VTE incidence was between 3% and 7% in this ED population with age and diagnosis of Achilles tendon rupture increasing risk. Prospective research to more accurately determine incidence, severity and risk stratification is required before firm recommendations on the likely risk versus benefit profile of thromboprophylaxis can be made for this population.
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