EMA December 2014

Issue 6 (Vol. 26) of EMA Journal for 2014 was published online on 1st December.

Ruling out subarachnoid haemorrhage (Abstract) Although uncommon, subarachnoid haemorrhage (SAH) is a potentially life-threatening cause of headache presentations to ED. For neurologically intact patients investigation for possible SAH is time consuming and has associated risks, so three clinical decision rules (CDRs) have been proposed to identify those patients with headache at high risk of SAH. This retrospective cohort study, from AM Kelly and colleagues, of 59 cases of diagnosed SAH demonstrated that CDR 2 (i.e. arrival by ambulance, age>45, vomited at least once & diastolic BP>100mmHg) had very high sensitivity (100%) and that the sensitivity of the other CDRs could also achieve 100% with addition of vomiting to the criteria. Although unlikely to reduce CT scan rates for patients with suspected SAH, these CDRs may assist in guiding further testing if CT scanning is negative

PIVCs in kids emergency  (#FOAMed) Peripheral intravenous catheters (PIVCs) are very commonly used devices for paediatric emergency medical care. This prospective cohort study, by Malyon et al, of 458 patients at the Royal Children’s Hospital (Queensland) found a median PIVC dwell time of 29h and that one quarter were removed due to device failure with over half of these not needing reinsertion suggesting redundancy for care. PIVC placement in the antecubital fossa, compared with the hand, was associated with a significantly increased risk for failure. The observed failure rates were high and many PIVCs appeared to remain in place longer than needed, suggesting that methods to reduce PIVC dwell times and rates of device failure in paediatric acute care settings should be considered.

CLINICAL PROCEDURES: Cardioversion  (#FOAMed) Synchronised direct current cardioversion is a treatment applicable to all tachyarrhythmias and is the most effective treatment for reversion of ventricular tachycardia. In this Clinical Procedure, Dr Luke Lawton gives tips on cardioverting patients including what energies to use for each arrhythmia, pad placement, sedation, the need for synchronisation and when cardioversion should be deferred. Specific advice on cardioverting patients with acute onset stable atrial fibrillation is also provided.

TRAINEE FOCUS: working & training in global health and international EM  (#FOAMed) This Trainee Focus explores training in global health (GH) and international emergency medicine (IEM) learning opportunities currently available to Australasian EM trainees. Jamieson and colleagues provide an introduction to this topic along with a useful checklist for those who may be interested in undertaking training terms in resource-limited environments. The collated perspectives from EM registrars – Thurtle, Keage and Wallis – describe the benefits and challenges of working in resource-limited settings, while Phillips gives practical advice based on her experience as a mentor and remote supervisor. Twitter feedback and web resources on GH and IEM are also provided

TRAINEE FOCUS: clinical fatigue management strategies  (#FOAMed) Following on from the Trainee Focus section in the last issue of EMA – which focused on the topic of night shifts – this article, from Cheng and colleagues, explores sleep deprivation and its effects on cognition, executive decision-making and the implications for clinical care. Practical advice on how to best manage shift work and lessen the impact of fatigue is provided.