EMA February 2013

Issue 1 (Vol. 25) of Emergency Medicine Australasia published online on 6 February 2013

Medical Reversal: What are you doing wrong for your patient today  (#FOAMed) This thought provoking editorial highlights the phenomenon of a new superior trial that contradicts contemporary clinical practice. Considering examples of medical reversals relevant to emergency medicine, Fatovich contends that much existing ‘expert’ practice, currently considered ‘safe and effective’ or a ‘standard of care’ and that seems ‘logical’ and ‘the right thing to do’, may turn out be ineffective or even harmful. Such paradigm shifts are difficult as they challenge long held beliefs, but should be embraced as the path to better patient care.

A Primer for Clinical Researchers in the Emergency Department:  Part V: How to Describe Data and Basic Medical Statistics (Abstract) In the final article in this series on key topics for clinicians conducting research as part of their work in the ED, Donath and colleagues discuss essential statistical concepts used in clinical research. Understanding the appropriate use of medical statistics is important for both researchers and those reading clinical research publications. Using practical clinical examples, concepts and tests frequently used for descriptive and inferential analyses in emergency medicine research are described. The importance of planning for data analysis in the research study design phase is also highlighted.Note: All five articles in the ‘A Primer for Clinical Researchers in the Emergency Department’ series will be collated and released as an online Virtual Issue in 2013

Introduction of an N-acetylcysteine (NAC) weight based dosing chart reduces prescription errors in the treatment of paracetamol poisoning (Abstract) Paracetamol overdose is common in Australasia with accurate prescribing and administration of NAC required for effective treatment and to avoid antidote toxicity. A pre- and post-intervention trial by McIntyre et al demonstrates that a weight based dosing chart (WBDC) can reduce overall NAC prescription errors in an ED setting. In particular, the WBDC significantly reduced clinically relevant major errors in NAC dose and infusion rate. The WBDC is a simple tool, providing NAC dose per weight in a standardised prescription according to Australasian guidelines, which can assist busy ED clinicians deal with complexities of recommended weight-based dosing regimens

Intern underperformance is detected more frequently in Emergency Medicine rotations (Abstract) A retrospective analysis, by Aram and colleagues, of assessment forms from interns in a tertiary referral hospital demonstrates that, while the prevalence of underperformance is low, the emergency medicine (EM) term detects more interns in difficulty than the other clinical rotations. The opportunities for supervision and assessment, along with case-mix experience, of the intern are key elements of the EM term. This finding is important in the current debate on the role of EM term and Medical Board requirements for internship

Triggers for Head computed tomography following Paediatric Head Injury: Comparison of Physician’s Reported Practice and Clinical Decision Rules (Abstract) Head trauma is a common paediatric ED presentation. Computed tomography (CT) scanning is an important diagnostic modality for patients with significant intracranial pathology, however long-term effects of exposure to ionising radiation and risks associated with sedation for CT are important considerations with paediatric patients. While high quality international clinical decision rules (CDRs) exist for head CT after paediatric head trauma, this multicentre survey by Lockie et al, from the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, demonstrates that clinical triggers used by senior Australasian emergency physicians to order paediatric head CT differ significantly from CDR recommended triggers. There is a need to prospectively validate the international CDRs in the Australasian setting before incorporating them into head injury clinical practice guidelines

Practical Management of the Shocked Neonate (#FOAMed) This perspective from Barker provides a practical approach to the recognition and initial management of shocked neonates presenting to the ED. Practical management includes the systematic use of aggressive fluid resuscitation, early inotropic support and ventilation. This is followed by consideration of the four major causes of neonatal shock – sepsis, cardiac disease, metabolic disease and non-accidental injury – initially suspecting and treating all four until definitive investigation