Journal Club Podcast May 2022 Dr Bertha Wu Dr David McCreary Prof Peter Cameron WELCOME TO THE MAY JOURNAL CLUB PODCAST. WE ARE JOINED BY PROFESSOR PETER CAMERON, ACADEMIC DIRECTOR FOR THE ALFRED EMERGENCY AND TRAUMA CENTRE, AND EMERGENCY PHYSICIAN DR DAVID MCCREARY. In May's journal club, we covered papers considering vasopressor choice in post OHCA patients in shock, trainee-supervisor power and trust dynamics in context of WBAs, front of neck access techniques, as well as effectiveness of sotrovimab in treating patients with risk of progressing to severe COVID-19. PAPER 1: EPINEPHRINE VERSUS NOREPINEPHRINE IN CARDIAC ARREST PATIENTS WITH POST-RESUSCITATION SHOCK READ IT HERE CLINICAL QUESTION: Does epinephrine cause more harm than norepinephrine in treating cardiac arrest patients with post resuscitation shock? WHY IS THIS TOPIC IMPORTANT: Poor survival after out of hospital cardiac arrest (10%) Only 1/3 admitted to hospital alive, of which, half to 2/3 die during ICU admission due to neurological injury or haemodynamic failure (refractory shock or recurrent cardiac arrest) Theoretical risk of harm for adrenaline use: increased cardiac contractility + heart rate à increased myocardial O2 demand à theoretically could exacerbate myocardial damage Few head-to-head studies comparing vasopressor use in OHCA. There had been some studies comparing epinephrine and norepinephrine in shock due to sepsis. A recent RCT looked at mortality between the epinephrine and norepinephrine arms in cardiogenic shock post MI, but the study was underpowered. No study has compared epinephrine and norepinephrine use in patients with post resuscitation shock DESIGN Registry-based, multicentre observational study Population Inclusion: Data of patients included in study was pulled from the Sudden Death Expertise Centre Registry in the Paris metropolitan area Patients admitted to five university hospitals alive and managed for post-resuscitation shock after OHCA from 2011-2018 were included Post resuscitation shock was defined as a need for vasopressors for more than 6hrs despite adequate fluid loading. The target mean was 65mmHg. Exclusion: Obvious extra cardiac cause of cardiac arrest eg trauma, drowning, drug overdose, electrocution, asphyxia due to external cause Refractory cardiac arrest without sustainable ROSC Refractory shock requiring extracorporeal membrane oxygenation Absence of continuous intravenous treatment with epinephrine or norepinephrine Pts who had continuous intravenous treatment with both epinephrine and norepinephrine were initially excluded, but later on included in additional analysis. INTERVENTION Epinephrine infusion during ICU stay COMPARISON Norepinephrine infusion during ICU stay OUTCOMES Primary outcome: All-cause hospital mortality during hospital stay Secondary outcomes: Cardiovascular hospital mortality (recurrent cardiac arrest or refractory haemodynamic shock) Unfavorable neurological outcome (Cerebral Performance Category 3-5) FINDINGS 766 patients from 5 hospitals were included in study à 285 (37%) received epinephrine, 481 (63%) received norepinephrine. Note, Table 1 in paper reported many difference in baseline features in the two groups. Patients in the epinephrine arm vs those in the norepinephrine arm had: Less patients with a shockable rhythm – 124 (44%) vs 276 (57%) A lower median pH at admission was lower – pH 7.17 vs pH 7.23 A higher arterial lactate at admission – 7.6 vs 4.8 Higher inotropic requirements – inotropic equivalent (IE) of 68 vs 49 (IE in ug/kg/min = dopamine + dobutamine + 100 x epinephrine + 100 x norepinephrine + 100 x isoproterenol = 15 x milrinone) More patients with myocardial dysfunction – 160 (72%) vs 229 (57%) Less patients who underwent a coronary angiogram – 186 (66%) vs 409 (85%) Less patients with targeted temperature management – 127(47%) vs 406 (85%) More patients with occurrence of OHCA at home – 171 (60%) vs 229 (48%) – but this was not statistically significant The study found that: All cause mortality was significantly higher in the epinephrine group (OR 2,6, 95% CI 1.4-4.7, P = 0.002) Cardiovascular hospital mortality was also higher with epinephrine (aOR 5.5, 95% CI 3.0-10.3, P < 0.001), as was the proportion of patients with CPC of 3-5 at hospital discharge Sensitivity analyses produced consistent results The analysis involving adjustment on a propensity score to control for confounder showed similar findings (aOR 2.1, 95% CI 1.1-4.0, P = 0.02) AUTHORS' CONCLUSIONS Among patients with post resuscitation shock after out of hospital cardiac arrest, use of epinephrine was associated with higher all cause and cardiovascular specific mortality compared with norepinephrine infusion. JOURNAL CLUB THOUGHTS The study question is an important one, but not an easy one to perform prospectively. Not unexpectedly, this retrospective registry-based study had some major issues with the study design. Importantly, there were many baseline differences between the two study arms. Essentially, patients in the adrenaline group sound much sicker to being with. The authors tried hard to compensate for confounders and differences between the groups by using various statistical maneuvers. However, you just can’t compare apples with oranges! In clinical practice, clinicians’ choice of vasopressors in patients with post-resuscitation shock is largely based on clinical judgement. Whether to use adrenaline vs noradrenaline in post-resuscitation shock is generally based on the cause of the patient's post-ROSC hypotension: cardiogenic vs inflammatory (distributive). In general, for the former, adrenaline tends to be used, and for the latter, noradrenaline would be the agent of choice. There were also potential flaws in the study’s statistical analysis. Whist performing multivariate logistic regression to adjust for confounders, independent variables should be used. Variables looked at in study (eg initial rhythm, time from collapse to CPR, time from CPR to ROSC, arterial pH, myocardial dysfunction) were dependent on each other (multicollinearity). So to account for codependence, conditional logistic regression has to be used. When the authors performed conditional logistic regression, no statistical difference was found between the epinephrine and norepinephrine arm. However, authors went on to perform propensity analysis on the conditional logistic regression – essentially performing statical analysis to adjust for confounders twice, in effect canceling each other out. BOTTOM LINE This is not a practice changing study, although it may be taken into account during out decision making when deciding whether to use adrenaline vs noradrenaline in patients with persistent shock post arrest (Ed. - unless you are of the same opinion as Dr McCreary, who feels this paper in no way can alter our clinical practice). It’s a hypothesis generating study – an RCT is needed to answer this question. PAPER 2: TRUST, POWER AND LEARNING IN WORKPLACE-BASED ASSESSMENT: THE TRAINEE PERSPECTIVE READ IT HERE CLINICAL QUESTION: How do trust and power dynamics between trainee and supervisor influence WBAs? SUMMARY This is a qualitative research paper with a clinical question of - how do trust and power dynamics between trainee and supervisor influence WBAs? Semi-structured interviews were performed on 17 anaesthetics trainees from Australia and New Zealand. The interviewers were the first author who was consultant anaesthetists (also Supervisor of Training and also supervises WBS), and a nonclinician clinical research assistant. It used a qualitative research method called the constructivist grounded theory (CGT) – a method that uses an inductive approach to generate a new theory from data gathered through participant interviews or focus groups. The aim of CGT is to understand and explore a social process where no adequate prior theory exists. As a results of the interviews, the authors theorized that WBA supervisor-trainee power dynamic is underpinned by an interaction of supervisor power over and trainee power to. Supervisor power over is the result of an expected natural order of a hierarchical environment. There is a reciprocal dominance and subservience in the supervisor/trainee relationship due to the power gradient. An example of this is trainees calling their supervisors “bosses” How supervisors use their power and how trainees respond to this can produce a different outcome for trainees Supervisor power over can provide trainees with multiple benefits: Provide norms for trainee and supervisor as to how to behave and relate to each other Clarified responsibility for patient care Interpersonal conflict avoided and facilitates a cordial and efficient working relationship Facilitate trainee access to specialist expertise and support in their learning Supervisors can influence trainee’s reputation, their progression in training and their access to future employment, for better or for worse Trainee power to reflects the trainees agency and how they choose to exercise their trust on supervisors. Trainees are more likely to initiate WBAs when they perceive that the encounter could be in their benefit supervisor demonstrate benevolent use of their power over eg had shown committment to trainees’ learning Trainees are reluctant to expose their own practise to supervisor scrutiny when they felt supervisors demand close control over patient care. Trainees minimise their vulnerability by: Withdrawing trust Complying closely to the supervisor’s wishes Matching their practise to the supervisor’s, ie “gaming” or “staging” their performance Trainees choose when to initiate formal assessments eg they avoid formal assessments with supervisors who they know to be unhelpfully critical AUTHORS' CONCLUSIONS The authors concluded that trainees’ trust in their supervisors was expressed in their use of their power to depending on how they perceived supervisors used their power over in WBAs: When trainees choose to trust in response to benevolent use of supervisor power, they are more likely to practise authentically and expose their weakness for the purpose of learning When trainees choose to trust less, eg with more “controlling” supervisors, they forgo their learning opportunities, and are likely to “game” or “stage their performance to match their practise to how they think they are expected to perform, With unsupportive and overly critical supervisors, trainees choose to avoid doing WBAs with them altogether The authors suggested a few ways to refine assessment systems to. rebalance the power dynamic between trainees and supervisors, with the aim to enhance trainee trust and mitigate trainee vulnerability Transparency in what performance information is considered in decision making Prospectively designating WBAs as either evidence for decision making or learning events to separate assessment of learning and assessment for learning Granting trainees some control over the selection of performance information presented to inform progress decisions JOURNAL CLUB THOUGHTS It’s a good to see clinical educators doing research on an area that is relatively new – WBAs have only been introduced quite recently. However, the study participants are anaesthetic trainees – supervision levels in anaesthetic training is very different to emergency training. Emergency trainees have to be independently practising at a much earlier stage of training. The interviewer in the study is also an anaesthetic consultant who is a supervisor of WBAs for anaesthetic trainees – it’s hard to imagine the conflict of interest did not affect the participants’ answers in some way. WBAs are somewhat tick boxes that ED trainees have to fulfil in order to complete training, but the stakes get higher as they approach the end of their training. One suggestion in our Journal Club is to focus on doing WBAs earlier in Advanced Training so the stakes are not so high – this way there is a better chance of trainee performing authentically for the purpose of learning. Another suggestion is to prospectively allocate WBAs so the trainee won’t get to “game” or stage” the performance as much. BOTTOM LINE The process of assessment via WBAs is not perfect. But at the end of the day, trainees can always get supervisors to informally assess their performance, independent to WBAs, in order to learn. PAPER 3: SUCCESS AND TIME TO OXYGEN DELIVERY FOR SCALPEL-FINGER-CANNULA AND SCALPEL-FINGER-BOUGIE FRONT-OF-NECK ACCESS: A RANDOMIZED CROSSOVER STUDY WITH A SIMULATED “CAN’T INTUBATE, CAN’T OXYGENATE” SCENARIO IN A MANIKIN MODEL WITH IMPALPABLE NECK ANATOMY READ IT HERE CLINICAL QUESTION: In "can't intubate, can't oxygenate" scenarios, is the scalpel-finger-cannula technique superior to the scalpel-finger-bougie technique in providing timely oxygenation? DESIGN Randomized prospective observational study conducted in the Department of Anaesthesiology, Intensive Care and Pain Medicine at Tan Tock Sen Hospital Singapore 65 Attending Anaesthetists or senior residents were invited to participate in study They attended scheduled basic FONA training, followed by advanced training on SFC and SFB cricothyrotomy On the same day, they performed both cricothyrotomy techniques under simulated conditions The order in which they perform either of the cricothyrotomy techniques were randomized POPULATION Interventions were performed on manikins in simulation scenarios Manikins simulated an obese patient with non palpable anatomy – trachea was 8cm deep, with lots of fake blood involved to simulate bleeding INTERVENTION Using the scalpel-finger-cannula (SFC) technique for front of neck access (FONA) followed by performing a Melker cricothyrotomy COMPARISON Using the scalpel-finger-bougie (SFB) technique for FONA OUTCOMES Primary: Time to in seconds from CICO declaration to oxygen delivery (defined as observation of manikin lung inflation), and First attempt success Each attempt was defined as the removal and reinsertion of the cannula or bougie Successful attempt was defined as oxygen delivery within 180 seconds of CICO declaration and within 3 or fewer attempts For SFC, the time for insertion of a Melker cricothyrotomy tube was recorded from the participant picking up the guidewire to successful oxygen delivery Deemed successful if the combined time for successful cannula and Melker cricothyrotomy was within 300 sec and within 3 or fewer attempts Secondary: Overall success Incidence of puncture through cricothyroid membrane Posterior tracheal wall damage Preferred FONA technique Pre-simulation and post-simulation confidence in SFC and SFC cricothyrotomies Satisfaction with the simulation model FINDINGS SFC was associated with a short time to oxygen delivery, with mean time difference -62.1s in multivariable analysis. Higher first attempt success was reported with SFC than SFB – 72.3% vs 27.7% Participants had higher odds at achieving first-attempt success with SFC bs SFB (OR 10.7, 95% CI 3.3-35.0, P <0.001) Successful delivery of oxygen after the CICO declaration within 3 attempts and 180sec was higher (84.6% vs 63.1%) and more likely with SFC (OR 5.59, 95% CI 1.7-18.9, P = 0.006) Analysing successful cases only, SFC achieved a shorter time to oxygen delivery (mean time difference -24.9s, 95% CI -37.8 to -12s, P < 0.001), but a longer time to cuffed tube I nsertion (mean time difference +56.0s, 95% CI 39.0-73.0, P < 0.001) After simulation training, most participants preferred SFC in patients with impalpable neck anatomy (75.3% vs 24.6%) AUTHORS' CONCLUSIONS In manikin simulation of impalpable neck anatomy and bleeding, the SFC approach demonstrated superior performance in oxygen delivery and was also the preferred technique of the majority of study participants. The study findings support the use of a cannula-based front of neck access technique for achieving oxygenation in a CICO situation, with the prerequisite that appropriate training and equipment are available. JOURNAL CLUB THOUGHTS It’s a good attempt in looking at an area that is very difficult to study. CICO situations don’t happen often (and I’d rather they never happen in my clinical practice!). However, this study is limited by being a manikin study. It’s also performed by experienced anaesthetists and anaesthetic registrars who have a different airway skillset to emergency physicians and trainees. The low pressure, rapid O2 delivery system is not readily available. In Australia, a high-pressure jet ventilation device like Manujet is available in most hospitals, but has a high incidence of complications eg device failure and barotrauma. With the scenario used in the study – an obese patient with a bleeding airway – how well can one oxygenate the patient with a small gauge cannula? Establishing a definitive airway for adequate oxygenation will be the priority in these patients. With the SFC technique, having steps to insert the Melker cricothyrotomy tube means extra time before a definitive airway is established. It also means extra cognitive load in a high-pressure high-stake situation. BOTTOM LINE In our patients (ED patients requiring emergency RSI), time to definitive airway using easy to access equipment is our priority. This study won’t change the most common practice in ED, which is to use the scalpel-finger-bougie technique. PAPER 4: EFFECT OF SOTROVIMAB ON HOSPITALIZATION OR DEATH AMONG HIGH-RISK PATIENTS WITH MILD TO MODERATE COVID-19 READ IT HERE CLINICAL QUESTION: Among patients at risk of disease progression, does early treatment of mild to moderate COVID-19 with sotrovimab prevent progression to severe disease? DESIGN Phase 3, double-blind, multicentre RCT conducted at 57 sites in Brazil, Canada, Peru, Spain and the US from 2020-2021 A part of a larger trial to evaluate the efficacy and tolerability of – COVID-19 Monoclonal Antibody Efficacy Trial – Intent to Care Early (COMET ICE) POPULATION Non-hospitalized patients with symptomatic, mild to moderate COVID-19 and at least 1 risk factor for progression Risk factors: Age >/= 55yo Diabetes requiring medication Obesity (BMI >30) CKD (eGFR <60) CCF (>/= NYHA class II) COPD Moderate to severe asthma Excluded: Hospitalized patients Signs or symptoms of severe COVID-19 (SOB at rest, SpO2 <94%, required supplemental O2) INTERVENTION Single intravenous infusion with 500mg of sotrovimab over 1 hour on day 1 (n=528) COMPARISON IV infusion with equal volume of placebo over 1 hour on day 1 (n=529) OUTCOMES Primary: Proportion of patients with COVID-19 progression through day 29 (all cause hospitalization lasting >24hrs for acute illness management, or death) Secondary: Composite of all-cause emergency department visit Hospitalization of any duration for acute illness management Death through day 29 Progression to severe or critical respiratory COVID-19 requiring supplemental O2 or mechanical ventilation FINDINGS Enrolment was stopped early for efficacy at the prespecified interim analysis. 1057 non-hospitalized patients with symptomatic mild to moderate COVID 19 and at least 1 risk factor for progression were enrolled. All cause hospitalization lasting longer than 24hrs or death was significantly reduced with sotrovimab – 6/258 (1%) vs placebo 30/529 (6%); adjusted RR 0.21 (95% CI 0.09 – 0.50); absolute difference -4.53% (95% CI, -6.00% to -2.37%), P < 0.001 Four of the 5 secondary outcomes were statistically significant in favor of sotrovimab, including Reduced ED visit, hospitalization or death – 13/528 [2%] for sotrovimab vs 39/529 [7%] for placebo; adjusted RR, 0.34 [95%CI, 0.19 to 0.63]; absolute difference, -4.91%[95%CI, –7.50% to –2.32%]; P < .001) Progression to severe or critical respiratory COVID-19 – 7/528 [1%] for sotrovimab vs 28/529 [5%] for placebo; adjusted RR, 0.26 [95%CI, 0.12 to 0.59]; absolute difference, –3.97%[95%CI, –6.11% to –1.82%]; P = .002) No patients treated with sotrovimab required HFNP, O2 via NBM or mechanical ventilation through day 29 Adverse events were infrequent and similar between treatment groups (22%for Sotrovimab vs 23%for placebo) AUTHORS' CONCLUSIONS Among non-hospitalized patients with mild to moderate COVID-19 and at risk of disease progression, a single intravenous dose of sotrovimab, compared with placebo, significantly reduced the risk of a composite end point of all-cause hospitalization or death through day 29. JOURNAL CLUB THOUGHTS This is somewhat a historical study now. The study enrolled patients over a finite period of the pandemic before vaccines were available and when the delta COVID strain was still at large. Now, a majority of people are vaccinated and omicron variants are the most common strains of COVID in the community. We know now that sotrovimab is less effective against omicron and variants so this study is somewhat not as relevant now. Additionally, there is a shortage of supply for sotrovimab. Current guidelines recommends using other antiviral agents like paxlovid and molnupiravir first. BOTTOM LINE Though not as relevant now, it’s still a good study to do as what we learn from sotrovimab can inform future efforts looking into therapies for other strains of COVID. REFERENCES Bougouin W, Silmanu K, Renaudier M et al. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022 Mar;48(3):300-310. Castanelli DJ, Weller JM, Moloy E, Bearman M. Trust, power and learning in workplace-based assessment: The trainee perspective. Med Educ 2022 Mar;56(3):280-291. Zhang J, Ong S, Toh H, et al. Success and Time to Oxygen Delivery for Scalpel-Finger-Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated "Can't Intubate, Can't Oxygenate" Scenario in a Manikin Model With Impalpable Neck Anatomy. Anesth Analg 2022 Mar 3. Gupta A, Gonzalez-Rojas Y, Juarez Erick, et al. Effect of Sotrovimab on Hospitalization or Death Among High-risk Patients With Mild to Moderate COVID-19A Randomized Clinical Trial.  JAMA.2022;327(13):1236-1246.MBBS, CCPU (eFAST, AAA, BELS). Emergency Medicine Advanced Trainee and Intensive Care Medicine Trainee in Melbourne, Australia. Particular interests in POCUS, medical education and health care in resource-poor settings. Twitter: @berthawu29 DR BERTHA WU Emergency Registrar MBBS, CCPU (eFAST, AAA, BELS). Emergency Medicine Advanced Trainee and Intensive Care Medicine Trainee in Melbourne, Australia. Particular interests in POCUS, medical education and health care in resource-poor settings. Twitter: @berthawu29

Journal Club Podcast June 2022 Dr Bertha Wu Dr Rob Mitchell Prof Peter Cameron WELCOME TO THE JUNE JOURNAL CLUB PODCAST. WE ARE JOINED BY PROFESSOR PETER CAMERON, ACADEMIC DIRECTOR FOR THE ALFRED EMERGENCY AND TRAUMA CENTRE, AND EMERGENCY PHYSICIAN DR ROB MITCHELL. We will discuss 3 papers this month, covering: delays to inpatient admission from ED and risk of death, use of anti-dopaminergic antiemetics and stroke risk, and the use of CT scans to rule out subarachnoid haemorrhages. PAPER 1: ASSOCIATION BETWEEN DELAYS TO PATIENT ADMISSION FROM THE EMERGENCY DEPARTMENT AND ALL-CAUSE 30-DAY MORTALITY. READ IT HERE CLINICAL QUESTION: Do delays to inpatient admission from EDs increase the risk of death? DESIGN Cross sectional, retrospective observational study POPULATION (TARGET) All patients admitted from every major ED in England between April 2016 and March 2018 Only a patient’s first admission in the study period was included. Patients who waited in the ED for longer than 12 hours were excluded INTERVENTION / COMPARISON No intervention/comparator as observational study Looked at exposure The time admitted patients spent in ED, up to 12 hours after arrival Times were measured from the patients’ arrival at the ED until their transfer to an inpatient bed OUTCOME Death from all causes within 30 days of admission FINDINGS Between April 2016 and March 2018, 26 738 514 people attended an ED, with 7 472 480 patients admitted. 5 249 891 individual patients data was included in the study Total of 433 962 deaths occurred within 30 days Overall crude mortality rate was 8.71% (95% CI 8.69% – 8.74%) Patients on average spent 5 hours in ED Of the admitted patients, 38% breached the 4-hour rule, which the paper used as a proxy for ED crowding. This is the variable with the largest OR for 30-d mortality of 1.35 (1.33-1.37, p<0.001) Lower socioeconomic status (measured on a patient deprivation decile of 1-10, with 1=least and 10=most deprived) was also associated with higher 30-d mortality with OR 1.20 for a deprivation decile of 7 and 1.32 for a decile of 10. Increased standardised mortality rate for patients admitted to hospital after 5 hours There is a dose-dependent association between time in excess of 5 hours in the ED for admitted patients and all-cause mortality The standardised mortality rate (SMR) increases in an approximately linear fashion from this point until 12 hours after which accurate data is unavailable There is a 10% increase in the SMR within 30 days for admitted patients remaining in ED between 8-12 hours in comparison with those who leave the ED within 6 hours. AUTHORS' CONCLUSIONS Delays to hospital inpatient admission for patients in excess of 5 hours from time of arrival at the ED are associated with an increase in all-cause 30-day mortality. JOURNAL CLUB THOUGHTS This paper’s findings are consistent with those from previous literature. From a methodological point of view, being a retrospective observational study, many confounders could have contributed to the paper’s findings. It was good that the authors addressed the possible mechanisms that may have accounted for patients’ prolonged stay in ED. However, there are nuances and complexities that were not mentioned by the paper. For example, disadvantaged patients like the elderly and confused or the complex medical patients are the ones who are usually get left behind, lingering for hours in ED waiting for an inpatient bed. BOTTOM LINE At the end of the day, access block is not an Emergency Department problem. It is a systemic problem that requires addressing with good leadership and a change of culture hospital-wide. PAPER 2: RISK OF FIRST ISCHAEMIC STROKE AND USE OF ANTIDOPAMINERGIC ANTIEMETICS: NATIONWIDE CASE-TIME-CONTROL STUDY. READ IT HERE CLINICAL QUESTION: Does the use of antidopaminergic antiemetics increase the risk of first stroke? DESIGN Case-time control study POPULATION (TARGET) >/= 18 years Diagnosis of first ischaemic stroke between 2012 and 2016 No history of cerebrovascular disease Had at least one reimbursement for the antidopaminergic antiemetics (ADA) studied – domperidone, metopimazine and metoclopramide – in the 70 days before stroke Were affiliated with the major health insurance scheme at least during the year of outcome occurrence. Eligible participants were all patients registered on the French health insurance database which contains information on at least 99% of the French population, and where reimbursements to outpatients for dispensed drugs can be found Included: Excluded: History of cancer Hospital admission in the observation period Had at least once reimbursement for the fixed association metoclopramide aspirin in the observation period on in the year before INTERVENTION / COMPARISON The two arms of the study are the case group (participants had first ischaemic stroke during study period), and the exposure time trend control group (participants who didn’t have an ischaemic stroke) Controls were recruited at the same time as the patients with stroke to take into the account of time trend of ADA use eg natural increase or decrease use of ADA over time This study looked at the two groups ‘ exposure to the studied ADAs over 4 periods: days -14 to -1 before stroke (the risk period), and days -70 to -57, -56 to -43, and -42 to -29 before stroke (reference periods) OUTCOME Association between ADA use and risk of ischaemic stroke Assessed by estimating the ratio of the odds ratios of exposure evaluated in patients with stroke and in controls WHAT WERE THE FINDINGS Amongst 2612 patients with incident stroke, 1250 received an ADA in the risk period, and 1060 in the reference periods The comparison with 5128 and 13165 respective controls who received an ADA in the same periods yielded a ration of adjusted odds ratio of 3.12 (95% CI 2.85-3.42) Analysis stratified by age, sex and history of dementia showed similar results Ratio of adjusted OR for analyses stratified by ADA was 2.51 (2.18-2.88) for domperidone, 3.62 (3.11-4.23) for metopimazine, and 3.53 for metoclopramide Sensitivity analysis suggested that the risk would be higher in the first days of use AUTHORS' CONCLUSIONS There is an increased risk of ischaemic stroke with recent ADA use. The highest increase was found for metopimazine and metoclopramide. JOURNAL CLUB THOUGHTS It was a great effort by the authors as there were a large number of participants. It was interesting that patients who had intravenous ADAs weren’t included, as one would imaging drugs given via the IV route would have the most intended or unintended effect. Further, the study did not detail why the patients required the ADA to being with. Was it because the patient developed vertigo as a prodrome of a posterior circulation stroke? Or that the patient had a significant illness that precipitated the stroke? The authors called this “protopathic bias” and did attempt to correct for this with a sensitivity analysis. However, this remains a design flaw that we’re not convinced can be adjusted for with statistical maneuvers. BOTTOM LINE The study findings are not convincing at a biological and clinical level, and won’t change our current practice. PAPER 3: SENSITIVITY OF MODERN MULTISLICE CT FOR SUBARACHNOID HAEMORRHAGE AT INCREMENTAL TIMEPOINTS AFTER HEADACHE ONSET: A 10-YEAR ANALYSIS. READ IT HERE CLINICAL QUESTION: Is it possible to extend the timeframe from headache onset within which modern multislice CT can be used to rule out aneurysmal subarachnoid haemorrhage (SAH)? DESIGN Single centre, retrospective cohort study POPULATION (TARGET) Patients who had diagnosis of subarachnoid haemorrhage presenting to Christchurch Hospital between 2007 and 2017Excluded: Traumatic SAH Repeat SAH admission during the study time period SAH found on postmortem in whom no MSCT was performed The day of onset of headache was not recorded Patient transferred to Christchurch Hospital from another hospital Patients with lost or destroyed records Cases miscoded as SAH INTERVENTION / COMPARISON Exposure: Imaging with multislice CT (MSCT) head OUTCOMES Primary: Proportion of patients with spontaneous aneurysmal SAH that had a positive MSCT Secondary: The proportion of patients with any type of spontaneous SAH that had a positive MSCT FINDINGS Out of 347patients with a SAH, 260 had an aneurysmal SAH MSCT identified 253 (97.3%) of all aneurysmal SAH and 332 (95.7%) of all SAH Of the 15 (2.7%) of patients not identified with MSCT, 7 (47%) were aneurysmal SAH diagnosed with SAH using a combination of LP and/or MRI Coroners mortality database was examined – no sudden deaths with SAH where patients had a recent related ED presentation where a head MSCT was performed There were 224 patients where the time of headache onset was not recorded Of these , onset was the same day as arrival in the ED in 148 (66%) of patients For these patients, the time of headache onset was imputed as 30min prior to arrival time for analysis to maximise the number of early false negatives For patients with headache onset during the preceding day, a time of 23:59 was imputed for analysis At 24 hours after headache onset, the sensitivity of MSCT for aneurysmal SAH was 100% (95% CI 98.3-100) At 48 hours after headache onset, the sensitivity of MSCT was 99.6% (95% CI 97.6-100) for aneurysmal SAH and 99% (95% CI 97.1-99.8) for all SAH The sensitivity of MSCT for all SAH decreased as time to MSCT increased AUTHORS' CONCLUSIONS It may be possible to extend the timeframe from headache onset within which modern MSCT can be used to rule out aneurysmal SAH JOURNAL CLUB THOUGHTS This study supports what many Emergency Physicians are doing currently. We know that with improvement of technology over the years, the sensitivity of CT brains and their ability to detect a subarachnoid haemorrhage beyond the 6 hours mark has also improved. Our experienced guest speakers recommended using clinical judgement when you decide what to do next after a negative CTB performed after 6 hours. There is little added benefit of performing a lumbar puncture. If there is a high pre-test probability of the patient having a subarachnoid haemorrhage, then a CT angiogram should be considered. BOTTOM LINE When a CTB is done beyond 6 hours of headache onset, whether any subsequent tests is required to rule out a SAH as the cause of the headache should be based on clinical judgement of pretest probability, taking into account that modern CT scanners have much better sensitivity to detect SAH. REFRENCES Jones S, Moulton C, Swift S, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J 2022 Mar;39(3):168-173. Benard-Laribiere A, Hucteau E, Debette S, et al. Risk of first ischaemic stroke and use of antidopaminergic antiemetics: nationwide case-time-control study. BMJ 2022;376:e066192. Vincent A, Pearson S, Pickering JW, et al. Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis. Emergency Medicine Journal. Published Online First: 24 November 2021. DR BERTHA WU Emergency Registrar MBBS, CCPU (eFAST, AAA, BELS). Emergency Medicine Advanced Trainee and Intensive Care Medicine Trainee in Melbourne, Australia. Particular interests in POCUS, medical education and health care in resource-poor settings. Twitter: @berthawu29

DR LUKE PHILLIPS EMERGENCY PHYSICIAN PEER REVIEW: DR EANNA MAC SUIBHNE WELCOME TO FAST FRIDAYS – A CASE-BASED, RAPID REVIEW OF A TOPIC. THE CASES HAVE BEEN ADAPTED FROM REAL PATIENTS BUT HAVE BEEN CHANGED FOR ANONYMITY AND TO EMPHASISE KEY LEARNING POINTS. THE CASE 23-year-old presents with knee pain and swelling post landing awkwardly on their right knee playing football. They now have pain and swelling to the knee and have difficulty weight bearing. On exam they have a large joint effusion and tenderness to lateral joint line. They can straight leg raise but any other assessment of knee joint integrity is limited by the swelling and pain. WHICH PATIENTS ACTUALLY NEED A KNEE X-RAY? Our Canadian friends, led by Stiell et al, have developed the Ottawa Knee Rule to identify low risk patients who may not need a knee X-ray. A knee x-ray series is only needed for knee injury patients with any of these findings: Age ≥ 55, OR Isolated tenderness of patella (no bone tenderness of knee other than patella), OR Tenderness of head of fibula, OR Inability to flex to 90°, OR Inability to bear weight both immediately after injury and in the ED for 4 steps (unable to transfer weight twice onto each lower limb regardless of limping. In an external validation study of the rule, the authors found a relative reduction in knee X-rays of 26.4% and a sensitivity of 100% for detecting knee fractures and a specificity of 48%. THE PATIENT MET CRITERIA FOR IMAGING AND X-RAYS WERE PERFORMED Case courtesy of Dr Luke Phillips, Radiopaedia.org. From the case rID: 99008 WHAT ARE THE KEY FINDINGS ON THESE X-RAYS? There is a moderate to large knee joint effusion. Avulsion fracture of the tibial spine at the distal ACL attachment. Avulsion fracture from the lateral knee capsule (Segond fracture)\ What is the significance of this fracture pattern? Segond fractures are avulsion fractures of the proximal-lateral tibia and represent a bony avulsion of the anterolateral ligament. It is associated with severe rotational instability of the knee. Identification of this finding on plain film radiographs should prompt further evaluation as they are rarely isolated injuries. They are pathognomonic for an Anterior Cruciate Ligament (ACL) tear, present in 75-100% of cases. Conversely, 9-12% of ACL ruptures have an associated Segond fracture. The presence of a tibial spine fracture and large haemarthrosis also indicates a likely ACL injury. EPONYMOUS OLD WHITE MAN ALERT Paul Ferdinand Segond (1851–1912) was professor of surgery at the University of Paris and surgeon in chief at the Saltpetriere. Although Segond was one of the foremost “knee specialists” in 19th century France, his significant contributions in this area were overlooked, and he is chiefly remembered for his contributions to gynaecologic surgery. WHAT ARE THE KEY MANAGEMENT OPTIONS? Management initially should be supportive, encouraging ice application, elevation compression and simple analgesia. Patients should be having restricted weight baring (initially using crutches but can toe touch, then progress to foot down if standing) and if there is complete knee instability or loss of extensor mechanism (ie patella fracture or quad/ patella tendon rupture) they should be provided with a Zimmer splint in the short term. They should be encouraged to retain some movement while sitting/ lying.  Gentle movement against gravity will help preserve quad strength, reduce effusion, retain range of movement & proprioception. Early Physio for “prehab” ("pre-op rehabilitation") is really important. This makes the operation easier and can  improve recovery in the longer term. Often patients will have operative management delayed until good ROM & strength similar (>90% of unaffected side). Patients should have an early orthopaedic referral for consideration of operative management including open repair of the fracture along with the ACL. There is no evidence for fixing the Segond fracture itself, any surgical intervention undertaken is aimed at repairing associated injuries. MRI will likely assist in further differentiating the injury and decision-making about ongoing management. Prognosis-wise, although Segond fractures are associated with a highly unstable knee, post-operative studies suggest no difference in tested stability after the ligamentous injury is addressed. Good news for our 23-year-old footballer! THE OUTCOME The patient was discussed with orthopaedics, discharged from the ED with a Zimmer Splint and was made non-weight bearing. A week later they underwent knee arthroscopy and repair of the tibial spine/ACL. The meniscus was intact. REFERENCES AND FURTHER READING: Davis DS, Post WR. Segond fracture: lateral capsular ligament avulsion. J Orthop Sports Phys Ther. 1997 Feb;25(2):103-6. doi: 10.2519/jospt.1997.25.2.103. PMID: 9007767. Shaikh H, Herbst E, Rahnemai-Azar AA, Bottene Villa Albers M, Naendrup JH, Musahl V, Irrgang JJ, Fu FH. The Segond Fracture Is an Avulsion of the Anterolateral Complex. Am J Sports Med. 2017 Aug;45(10):2247-2252. doi: 10.1177/0363546517704845. Epub 2017 May 12. PMID: 28499093. Arneja SS, Furey MJ, Alvarez CM, Reilly CW. Segond fractures: not necessarily pathognemonic of anterior cruciate ligament injury in the pediatric population. Sports Health. 2010 Sep;2(5):437-9 https://en.wikipedia.org/wiki/Paul_Segond https://pubs.rsna.org/doi/full/10.1148/radiographics.20.3.g00ma20819 Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Practice & Research Clinical Rheumatology. 2019 Feb;33(1):33–47. LUKE PHILLIPS Emergency Physician Dr Luke Phillips is an Emergency Physician at Alfred Health in Melbourne and currently the Co-Director of Emergency Medicine Training. He is a passionate educator and has been fortunate enough to be able to combine this with his love of emergency ultrasound. Luke has a special interest in the use of focused ultrasound for critically unwell patients, in trauma management and in the use of ultrasound to guide procedures and improve patient safety in the ED. He is currently the Co-Chair of the Emergency Medicine Ultrasound Group (EMUGS.org) Board of Directors and holds a number of CCPU units through ASUM. Luke is also involved in the department’s international education program and has developed a Certificate of Emergency Medicine which is currently being run in both Germany and India. He also has interests in human factors, debriefing (particularly after clinical events), and simulation. His Twitter handle is @lukemphillips.

Dr Hector Thomson Emergency Registrar Peer review: Dr Binula Wickramarachchi While recent cases of Japanese Encephalitis have caught headlines, I recently stumbled across a disease I was embarrassed to say I had never heard of. My paediatric-trained colleagues all seemed to have heard of it, but I could scarcely find a mention in my ED textbooks, maybe because the diagnosis is never made downstairs and we call it viral meningitis pending a culture. With a waiting room full of kids with viral URTIs, I now have a new disease to look out for along with PIMS-TS. Let me tell you about some more scary capital letters: ADEM. So, what is ADEM? ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM) ADEM is an autoimmune demyelinating disease of the central nervous system (CNS) which is monophasic (has a single occurrence) but multifocal in nature. So, lots of cool neurological signs but then they don’t go away; in contrast to MS, for example,  where they may fluctuate. It's most commonly seen in children, though adults can also be affected. It was first described by Mr James Lukas, a surgeon in Leeds in the 18th Century, as "uncommon symptoms succeeding the measles". CRITERIA FOR DIAGNOSIS All of the following are needed, along with reasonable exclusion of other possible neurological conditions: A first multifocal clinical CNS event of presumed inflammatory demyelinating cause Encephalopathy: stupor and/or lethargy or behavioural changes unexplained by fever, systemic illness or postictal symptoms An abnormal MRI brain during the acute phase (3 months) No new clinical or MRI findings >3 months after clinical onset CAUSE It isn’t clear what exactly causes ADEM but as with many autoimmune conditions, the current theory is that an infectious or environment trigger in a genetically susceptible child causes an autoimmune attack on the CNS resulting in demyelination. The disease typically starts with an abrupt onset within a day to weeks after a viral infection (75%) or immunisation. Common viruses (Epstein-Barr, measles, mumps, rubella, and Coxsackie B) are the most common pathogens associated with postinfectious ADEM. COVID has been reported as a cause but a review this year only found 31 reported cases. Bacterial triggers are rare and less than 5% of ADEM cases follow immunisation. These have most often been associated with the MMR vaccination. PRESENTATION The classic presentation is a 2-5 day prodrome where fever, nausea, vomiting, headache, and weakness may be present, followed by acute-onset, rapidly progressive encephalopathy and multifocal neurological symptoms. Encephalopathy comprises change in behaviour and/or conscious state and can range from lethargy and irritability to coma. A wide variety of neurological deficits can be manifested, determined mainly by the localization of lesions.  80% will have a motor deficit, 50-60% ataxia, and up to 50% will have a cranial nerve deficit with optic neuritis, often bilaterally. Yes, that means you have to go find the tendon hammer and try and get those grumpy toddlers to walk for you! Systemic features are common, with fever (50%), headache (40-50%) and vomiting (30%) occurring frequently. 10-30% will have seizures and case series have shown between 3-25% have concurrent spinal cord involvement. UK data suggests 25% of children with ADEM will need ICU level care. The majority of cases follow a monophasic course, but patients may have recurrence of initial symptoms (recurrent ADEM) or a second episode (multiphasic ADEM). EPIDEMOLOGY ADEM can occur at any age but is most common in children (mean age 5–8 years old), with a slight male predominance. Tracking the rate of ADEM is difficult as the majority of paediatric encephalitis hospitalisations never have a cause identified. Australian data identifies the incidence of ADEM at 0.68-0.79 per 100 000 person years in people aged < 14. Higher than quoted numbers in the US, UK and Asian countries. INVESTIGATIONS The diagnosis of ADEM is clinical but MRI seems to be the most important investigation. T2 and FLAIR sequences will show multiple areas of demyelination in the brain and spine. CT is not sensitive and can be reported as normal.  Lumbar puncture may show pleocytosis and increased protein. EEG may show non-specific diffuse or less commonly focal slowing of background activity. Someone may ask you to order MOG IgG and aquaporin-4 (AQP4) IgG serum autoantibody. For me, these go into the bag of the “did ya” tubes. 🤓 DEFINITION: “DID YA” TUBES. A Hectorism. When taking blood, the process of storing excess in a serum storage tube in anticipation of a specialty registrar calling you back to ask for extra tests they have just read about on UpToDate. DIFFERENTIAL In the emergency department, you will be faced with an encephalopathic child with focal neurology. The important differential to rule out in these children is acute CNS infection and these children should always be covered with antibiotics and antivirals. The list of differentials is extremely long. The consensus guidelines for investigation of encephalitis list hits every major disease group. Other key things to rule out are: Space occupying lesion Traumatic brain injury Metabolic encephalopathy Seizure disorder It may be useful to frame this rare disease with something more familiar. Doesn’t this so far just sound like MS? Well yes, but there are important differences. The most relevant being that in MS there should not be any features of encephalopathy. Image courtesy of: Dale RC, Branson JA Acute disseminated encephalomyelitis or multiple sclerosis: can the initial presentation help in establishing a correct diagnosis? Archives of Disease in Childhood 2005;90:636-639 TREATMENT Corticosteroids are the established first-line therapy (this is neurology, after all). There are no RCTs, but small paediatric case series dictate the standard protocol as being IV methylprednisolone followed by oral prednisolone for 4 weeks. The use of immunoglobulin and plasmapheresis have only been published in very small case series in children, and mostly in those that have not responded to steroids. PROGNOSIS The good news is that thankfully, most of these kids do very well. 65-85% of paediatric ADEM patients have a good functional outcome and improvement is usually seen within a few days of starting treatment. Whether this is just the natural course of the illness or due to the steroids is a point of debate. Mild neurocognitive deficits and behaviour problems are not uncommon, with children younger than 5 being at higher risk. SCARY FORM In a small proportion, the course is more fulminant, frequently resulting in death. In such cases, the lesions may demonstrate haemorrhage and the condition is then known as acute haemorrhagic leukoencephalitis (Hurst disease). This disease appears to have overlap with cerebral vasculitis. ED PERSPECTIVE I don’t think we should, or are likely to be making this diagnosis. It definitely helps to know it exists, though. In the 4-year-old with irritability and focal neurological findings our job is to not send them home, empirically treat dangerous infections and facilitate appropriate investigations. Accessing sedation and imaging lists can be challenging for inpatient teams, so do your best to help with facilitating these, and advocate for these patients. I’m going to try and remember this as the drunk toddler who just got over a cold. Irritable, staggering around and can’t see straight. TAKE HOME MESSAGES ADEM often presents 1-4 weeks after a febrile illness Do your best to do a complete a neuro exam on the irritated toddler – focal findings should make you stop and think hard about not just “another URTI” ADEM remains a clinical diagnosis, however, early MRI is key for early diagnosis and prompt initiation of treatment. We should do our best to help facilitate these tests Empirically give antibiotics and antivirals ADEM is treated with high dose steroids +/- IVIG or plasmapheresis REFERENCES / WANT TO READ MORE? GUIDELINES Krupp LB, Tardieu M, Amato MP, Banwell B, Chitnis T, Dale RC, et al. International pediatric multiple sclerosis study group criteria for pediatric multiple sclerosis and immune-mediated central nervous system demyelinating disorders: revisions to the 2007 definitions. Mult Scler. 2013;19(10):1261–7. Britton PN, Eastwood K, Brew B, Nagree Y, and Jones CA. Consensus guidelines for the investigation and management of encephalitis. Med J Aust 2015; 202 (11): 576-577. || doi: 10.5694/mja14.01042 Filippi, M., Rocca, M.A. (2020). Acute Disseminated Encephalomyelitis. In: White Matter Diseases . Springer, Cham. doi: 10.1007/978-3-030-38621-4_5 CASE SERIES McLendon LA, Rao CK, Da Hora CC, Islamovic F, Galan FN. Post-COVID-19 Acute Disseminated Encephalomyelitis in a 17-Month-Old. Pediatrics. 2021 Jun;147(6):e2020049678. doi: 10.1542/peds.2020-049678. Epub 2021 Mar 24. PMID: 33762311. Huynh W, Cordato DJ, Kehdi E, Masters LT, Dedousis C. Post-vaccination encephalomyelitis: literature review and illustrative case. J Clin Neurosci. 2008 Dec;15(12):1315-22. doi: 10.1016/j.jocn.2008.05.002. Epub 2008 Oct 30. PMID: 18976924; PMCID: PMC7125578. Bisker Kassif, O., Orbach, R., Rimon, A., Scolnik, D., & Glatstein, M. (2019). Acute disseminated encephalomyelitis in children - clinical and MRI decision making in the emergency department. The American Journal of Emergency Medicine, 37(11), 2004–2007. doi: 10.1016/j.ajem.2019.02.022 Absoud M, Parslow RC, Wassmer E, Hemingway C, Duncan HP, Cummins C, Lim MJ; UK & Ireland Childhood CNS Inflammatory Demyelination Working Group and the the Paediatric Intensive Care Audit Network. Severe acute disseminated encephalomyelitis: a paediatric intensive care population-based study. Mult Scler. 2011 Oct;17(10):1258-61. doi: 10.1177/1352458510382554. Epub 2010 Sep 27. PMID: 20876155. George T, Basin A, Avva U, Taylor M, Muhammed J, Ogedegbe C. Early Recognition and Treatment of Acute Disseminated Encephalomyelitis in Pediatrics: A Case Series. Pediatr Emerg Care. 2019 Apr 9. doi: 10.1097/PEC.0000000000001771. Epub ahead of print. PMID: 30973501. Tenembaum S, Chamoles N, Fejerman N. Acute disseminated encephalomyelitis: a long-term follow-up study of 84 pediatric patients. Neurology. 2002;59(8):1224–31 Ravaglia S, Piccolo G, Ceroni M, Franciotta D, Pichiecchio A, Bastianello S, et al. Severe steroid-resistant post-infectious encephalomyelitis: general features and effects of IVIg. J Neurol. 2007;254(11):1518–23. Keegan M, Pineda AA, McClelland RL, Darby CH, Rodriguez M, Weinshenker BG. Plasma REVIEWS Leake JA, Albani S, Kao AS, Senac MO, Billman GF, Nespeca MP, Paulino AD, Quintela ER, Sawyer MH, Bradley JS. Acute disseminated encephalomyelitis in childhood: epidemiologic, clinical and laboratory features. Pediatr Infect Dis J. 2004 Aug;23(8):756-64. doi: 10.1097/01.inf.0000133048.75452.dd. PMID: 15295226. Berzero G, Cortese A, Ravaglia S, Marchioni E. Diagnosis and therapy of acute disseminated encephalomyelitis and its variants. Expert Rev Neurother. 2016;16(1):83–101. Koelman DL, Mateen FJ. Acute disseminated encephalomyelitis: current controversies in diagnosis and outcome. J Neurol. 2015;262(9):2013–24. Britton PN, Khoury L, Booy R, et al. Encephalitis in Australian children: contemporary trends in hospitalisation. Archives of Disease in Childhood 2016;101:51-56. HECTOR THOMSON Emergency Registrar Hector (the one on the left) is an Emergency Medicine Advanced Trainee at The Alfred. He’s still clinging to the basic science knowledge he gained during primary exam prep and enjoys shoulder dislocations, trauma, rugby union, fresh pasta and good gin. He doesn’t like vague allergies or cats.

Dr Binula Wickramarachchi & Dr Luke Phillips Welcome to our Unlocking the ACEM Exams blog posts where we unlock the key study habits, resources and top tips from recent successful exam candidates.  This week we got to sit down with Dr Binula Wickramarachchi who recently completed a successful sitting of the ACEM fellowship OSCE exam (2022.1). Binula outlines some of his key tips to success in the post below. DR BINULA WICKRAMARACHCHI Binula is an Emergency Advanced Trainee and Education Fellow at the Alfred Hospital. He grew up among the verdant hills of Auckland, New Zealand, obtaining his medical degree and Postgraduate Diploma in Clinical Education at the University of Auckland. He also has a passion for point of care ultrasound, particularly echo and lung ultrasound. At home, Binula is a devoted parent to his two feline daughters, and is the household co-lead for the acclimatisation to a new human child. "HOW DID YOU PREPARE FOR THE EXAM?" A frequent, consistent and supportive study group is a must Don't underestimate the value of repeating stations, especially a day or two following a good learning encounter Identify your deficiencies early and work on these. It can be easy to keep patting yourself on the back for something you're already good at Practice with a range of FACEM's, including newer and more experienced ones. It is especially helpful to practice with ones that will be more critical with you, but try to avoid this closer to the exam "WHAT ARE YOUR TOP TIPS FOR SUCCESS?" Be adaptable - many of the cases you will face in the exam, you won't have seen before, or will be presented in a different context/format. You have to be able to answer the questions that are presented, not necessarily what you have practiced. Practice speaking confidently, concisely and in a structured manner. Appropriate language has a huge effect on how you're perceived. "DO YOU HAVE AN PEARLS ABOUT REFINING YOUR EXAM TECHNIQUE?" Use the pace of your speech effectively: (i) Slow down for empathy, (ii) Speed up for factual information, (iii) Use silence appropriately when breaking bad news or giving complex information. Use reading time effectively: (i) Actively read the stem and extract all the information you can from it. (ii) This can help you to pre-empt where you think the station will go, but be careful to not assume too much, and to adapt if it turns an unexpected corner If props are provided, extract all relevant information from them outside the room. This way, you can focus on answering the questions in the station, rather than spend time interpreting inside the room. For example: (i) Do the blood gas calculations, (ii) Interpret the X-rays/ECGs fully. Do as many trial exams as possible - each one will make you that much more comfortable with the exam process. (i) Speak to your DEMT or OSCE exam facilitator about how to get involved in these. "ANY RESOURCES YOU WOULD RECOMMEND?" Comm's Lab with Dr Hayden Richards (YouTube) - This is a gold mine of really useful communication strategies. End of life discussions Don Liew's personal coaching and trial exams - I found the coaching very individualised and helpful in practicing to iron out my weaknesses. As above, the trial exam was great for further practice. Various online question banks available - get your hands on these early and organise them so practice comes easily. Speak to recent exam graduates about how to get ahold of these resources.

Journal Club Podcast January 2023 Dr Danny Marhaba Dr Rob Melvin Professor Peter Cameron Welcome to the first Journal Club Podcast of 2023. We are joined by Professor Peter Cameron, Academic Director for the Alfred Emergency and Trauma Centre and Dr Rob Melvin, Emergency Consultant and Deputy Director at Alfred Emergency and Trauma Centre. This month has a paediatric theme with papers looking at: immobilisation of torus fractures, the mid-arm point for paediatric ICC insertion, and screen time in paediatric concussion. IMMOBILISATION OF TORUS FRACTURES OF THE WRIST IN CHILDREN (FORCE): A RANDOMISED CONTROLLED EQUIVALENCE TRIAL IN THE UK READ IT HERE CLINICAL QUESTION Is rigid immobilisation necessary in paediatric buckle fractures of the distal radius? JOURNAL The Lancet, July 2022 LEAD AUTHOR Daniel C Perry BACKGROUND Buckle Fractures of the distal radius are among the most common fractures in children {1}. Fractures of the distal radius can be classified as those affecting the growth plate (physis), those involving the metaphysis and/or those affecting the diaphysis. There has been a wide variation of practice recommendations in the management of buckle fractures of the distal radius, with some recommending rigid immobilisation and others recommending bandaging {2,3,4}. A 2018 Cochrane review into the treatment of buckle fractures concluded that they were unable to recommend a particular treatment strategy (partly due to the low quality of evidence), however, they did note that their review findings were consistent with the move away from cast immobilisation for buckle fractures {5}. DESIGN Multicentre, Randomised, Controlled, Equivalence Trial Population665 children 8 – 15 years of age, and 300 children 4 – 7 years of age, who presented to one of 23 emergency departments in the UK, with a radiologically confirmed buckle fracture of the distal radius. Excluded were children whose injuries were ≥36 hours old, children who’s clinician suspected a cortical disruption of the radius, or those deemed unable to adhere to trial procedures (insufficient English, no internet, developmental delay, etc). EXPOSURE Bandage offering and immediate discharge. ComparisonRigid immobilisation with splint, back-slab or cast and follow up as per treatment centre protocol. OUTCOME Primary: Pain at 3 days, as measured by the WBFPS (Wong Baker Faces Pain Scale). Secondary Outcomes A collection of findings including days of school or childcare absence at 3 and 6 weeks, return to hospital at 1/3/6 weeks, and patient satisfaction using a 7-item Likert scale. FINDINGS Primary Outcome Children in the exposure group (bandage and discharge) had a mean WBFPS of 3.21, compared with 3.14 in the comparator group (rigid immobilisation), with CI -0.37, 0.17. Secondary outcomes: No significant difference in pain at any measured time-point. No significant difference secondary outcomes in function questionnaires. Statistically significant difference in parent satisfaction on day 1 and analgesia use on day 1. While not statistically significant, trend for bandage group to be more likely to have used analgesia (except D1), and have missed school. AUTHORS' CONCLUSIONS The authors report that their trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius, between bandage and rigid immobilisation. They also report do between-group differences in pain or function during the 6 weeks of follow up. BOTTOM LINE This trial reaffirms that a bandage or tub-grip results in equivalent outcomes, save for some increase in use of basic analgesia. Splints here are a good option to have, but in this particular injury, rigid immobilisation is just not necessary – whether there is a concurrent ulnar fracture or not. Orthopaedic clinics are often full, and to be able to avoid unnecessary referrals to this clinic likely represents good stewardship of social resources. An equivalence trial has more steps than a traditional difference of means trial, in that one would need to disprove two null hypotheses rather than just one. The first null hypothesis to disprove is that the exposure increases the outcome variable by a certain measure of association. The second null hypothesis to disprove is that the exposure reduces the outcome variable by a certain measure of association. Disproving both, therefore shows that the exposure is equivalent to the comparator, to a certain statistical significance and minimum clinically important difference. 🎧 Podcast editor, Dave McCreary, also discussed this study on the RCEMLearning podcast, you can hear that here. 🎧 MID-ARM POINT IN PAEDIATRICS (MAPPAED): AN EFFECTIVE PROCEDURAL AID FOR SAFE PLEURAL DECOMPRESSION IN TRAUMA READ IT HERE CLINICAL QUESTION: Can the Mid Arm Point be used for landmarking ICC insertion in children? JOURNAL Emergency Medicine Australasia, November 2022 LEAD AUTHOR Nuala Quinn BACKGROUND In 2022, injuries were responsible for 33% of all deaths in Australian children {8}. Of those severely injured children, many are at risk of dying from thoracic injuries requiring emergency pleural decompression {9}. In one audit of a high-volume trauma service, 41% of intercostal catheters in children, were placed outside of the triangle of safety {10}. The Mid Arm Point is used in some adult trauma centres, and has been reported to be a reliable aid in placement {11}. DESIGN Prospective Cohort Study, compared to a presumed gold standard Population (Target)392 children aged ≤18 years, who attended one of four emergency departments in Australia and Ireland, who required a chest X-ray for any reason. POPULATION (TARGET) 392 children aged ≤18 years, who attended one of four emergency departments in Australia and Ireland, who required a chest X-ray for any reason. EXPOSURE Mid Arm Point measured and the chest wall marked at that level, a radio-opaque sticker was placed on the mark and an X-Ray was taken with the arms abducted. COMPARISON A presumed gold standard of intercostal space (ICS) 4–6, as identified on the chest x-Ray by a consultant radiologist. OUTCOME Primary Outcome: The proportion of markers localized to ICS 4–6 by interpretation of a consultant radiologist, versus those that identified as ICS 1-3 (too cranial) and those that were identified as ICS 7-8 (too caudal). Post Hoc Analysis: The proportion of markers localised to ICS 4–6 after a single ICS adjustment for age, chosen as ≥4 years. WHAT WERE THE FINDINGS? 712 markers were placed and xrayed following exclusion criteria, 353 (50%) Left sided 359 (50%) right sided. Using the MAP technique throughout all ages found 81% success, with malposition favouring more caudal placement - 14% in ICS 6th and 7th, with only 3% above 4th space. Patients between age 4-18 had higher rates of malposition and of those they were largely placed too caudal (22.6%). Post Hoc analyses showed an increased overall success rate to 91% if a MAPPAED rule was applied to ages 4-18 where the intercostal space above the marked space was used. AUTHORS' CONCLUSIONS Adopting the MAP and MAPPAED approach may improve these success rates of appropriate positioning in the safe zone, and reduce cognitive load on emergency and prehospital clinicians. The MAP rule requires a modification to ages 4-18 which likely represents non-linear relative discrepancies in growth patterns of upper limb and thoracic cage. CLINICAL BOTTOM LINE This is an excellent study. It is simple, straightforward, and represents a creative and pragmatic way to gather clinically useful evidence. For most emergency physicians, ICC insertion in children is rare. Using the Mid-Arm-Point in children <4 and moving 1 ICS superiorly to the Mid-Arm-Point in children ≥4 represents a significant reduction in cognitive load for what may be a complex resuscitation. Producing a good quality, prospective, randomised controlled trial in this patient group is fraught with challenges, if at all feasible. The MAPPAED study may well be some of the best evidence that exists in paediatric ICC insertion for some years to come. The primary limitation however, is in the post-hoc analysis in children ≥4 years. This is because a statistical test is most valid when tested against a pre-conceived single primary outcome, as opposed to identifying a group of retrospectively generated patterns. One could say that the MAPPAED rule, has been prospectively tested in children <4 years of age outside of a major trauma resuscitation, and that the MAPPAED adjustment, has been retrospectively identified in children ≥4 years of age outside of a major trauma resuscitation. EARLY POSTINJURY SCREEN TIME AND CONCUSSION RECOVERY READ IT HERE CLINICAL QUESTION: Does a reduction in screen time facilitate recovery from paediatric concussive head injuries? JOURNAL Pediatrics, November 2022 LEAD AUTHOR Molly Cairncross BACKGROUND Screen-time restrictions are often recommended by clinicians providing care for paediatric patients with a post-concussive head injury {6}. In 2021, a randomised trial of 125 patients between 12 – 25 years of age was conducted published in JAMA-Pediatrics, and provided some much-needed evidence for this recommendation {7}. However, the actual screen-time recorded for the screen-time restricted group was a median of 130 minutes per week (compared to 630 minutes in the screen-time permitted group). Unanswered questions into the optimal screen-time recommendation therefore persist. Design Retrospective Cohort Study - (Planned secondary data analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) study) POPULATION (TARGET) Seven hundred and twelve children aged 8 – 16 years, who presented to one of five Canadian Emergency Departments, between September 2016 and December 2018, with blunt head trauma and symptoms consistent with a concussion. Exclusion criteria were children with neurological deterioration, neurosurgical intervention, LOC > 30 min, amnesia > 24hrs, and abbreviated injury scale (AIS) > 4. EXPOSURE Self-reported screen-time measured weekly for 3 months, in patients with a diagnosed concussive head injury. COMPARISON Self-reported screen-time measured weekly for 3 months, in patients with a diagnosed orthopaedic injury. OUTCOME Primary: Differences in the association with the Health and Behaviour Scores, between the two groups, measured weekly for 3 months. Secondary Outcomes Secondary: A collection of other pre and post injury factors and measures of association with post concussive symptoms. WHAT WERE THE FINDINGS? Screen time was a significant but nonlinear moderator of group differences in post-concussion symptom severity for parent-reported somatic (P = .01) and self-reported cognitive symptoms (P = .03). Low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the OI group during the first 30 days postinjury but not after 30 days. Other risk factors and health behaviours had stronger associations with symptom severity than screen time. AUTHORS' CONCLUSIONS The interaction between self-reported screen time and post concussive symptoms is not linear. They recommend moderation in screen-time rather than abstaining from it. CLINICAL BOTTOM LINE This is a retrospective cohort study of an intervention – and the study design comes with many confounders. Concussive symptoms themselves may have many modifiers on both quantity and quality of screen time – they may be simply staring at the screen rather than engaging with it. Another challenge to the conclusions of the study are the nature of self-reported data on screen time. The fact that there was only a moderate correlation between parent and child – reported screen-time (Spearman’s r = .6) highlights this challenge. For now, it is likely reasonable to recommend moderation in screen-time for children who have suffered a concussion. REFERENCES Chung KC & Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am.2001; 26: 908-915 National Clinical Guideline Centre (UK). Fractures (non-complex): assessment and management. (NG38). 2016. https://www.nice.org.uk/guidance/ng38 Children’s Health Queensland Hospital and Health Service. Buckle Fractures . https://www.childrens.health.qld.gov.au/fact-sheet-buckle-fractures/. Accessed January 2023. Royal Children’s Hospital, Melbourne. Distal radius and / or ulna – metaphyseal fractures. https://www.rch.org.au/clinicalguide/guideline_index/fractures/Distal_radius_and_or_ulna_metaphyseal_fractures_Emergency_Department_setting/ (Clinical Practice Guideline). Accessed January 2023. Handoll HH, Elliott J, Iheozor-Ejiofor Z, Hunter J, Karantana A. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev. 2018 Dec 19;12(12):CD012470. doi: 10.1002/14651858.CD012470.pub2. PMID: 30566764; PMCID: PMC6516962. Queensland Health. Recovery after a concussion (Patient Fact Sheet). https://www.health.qld.gov.au/news-events/news/recovery-after-concussion. Accessed January 2023. Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion:A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124–1131. doi:10.1001/jamapediatrics.2021.2782 Australian Institute of Health and Welfare. Infant and Child Deaths. https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/infant-child-deaths. Accessed January 2023. Quinn N, Palmer CS, Bernard S, Noonan M, Teague WJ. Thoracostomy in children with severe trauma: an overview of the paediatric experience in Victoria, Australia. Emergency Medicine Australasia. 2020; 32: 117–26. Kong VY, Oosthuizen GV, Sartorius B, Keene C, Clarke DL. An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Aftrica. Annals of the Royal College of Surgeons of England. 2014; 96: 609–13. Bing F, Fitzgerald M, Olaussen A et al. Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP). Journal of Emergency Medicine, Trauma and Acute Care 2017.Danny is an Emergency Medicine Registrar at the Emergency and Trauma Centre and the current Senior Registrar for research. He trained in regional NSW before moving back to Melbourne to complete his training at the Alfred. DR DANNNY MARHABA Emergency Registrar Danny is an Emergency Medicine Registrar at the Emergency and Trauma Centre and the current Senior Registrar for research. He trained in regional NSW before moving back to Melbourne to complete his training at the Alfred.

Journal Club Podcast February 2023 Dr Danny Marhaba Dr David McCreary Professor Peter Cameron Welcome to the second Journal Club Podcast of 2023. We are joined by Professor Peter Cameron, Academic Director for the Alfred Emergency and Trauma Centre and Dr David McCreary, Emergency Consultant at Alfred Emergency and Trauma Centre. BACKGROUND - A Primer on the history of Sepsis Literature Wholistic discussions around sepsis can begin from 1991, when the ACCP (American College of Chest Physicians) and the SCCM (Society of Critical Care Medicine) convened a “Consensus Conference,” which as other conferences to follow implied, might be referred to as – Sepsis 1 {1}. This consensus defined sepsis as a response to infection manifested by ≥2 SIRS criteria. In 2001, this group expanded to include the ESICM (European Society of Intensive Care Medicine), the ATS (American Thoracic Society), and the SIS (Surgical Infection Society); their new definition – colloquially referred to as Sepsis 2 – largely maintained the definitions and divisions of sepsis, severe sepsis and septic shock {2). In parallel the now infamous Rivers Trial, where a bundle of interventions termed EGDT (Early Goal Directed Therapy), showed that this bundle when applied to the 130 out of 263 patients with severe sepsis or septic shock who were randomised to its arm, dramatically reduced in hospital mortality from 44.4% to 29.2% {3}. This single centre trial with a relatively high control-group mortality led to the now well-known Surviving Sepsis campaign recommended the interventions of EGDT and continued doing so for the decade that followed {4, 5} – specifically, this was an era that can be differentiated by relatively liberal blood transfusions, continuous central venous co-oximetry, and dobutamine. The differences in actual interventions received such as transfusions, pulmonary artery catheterisation and intubation are shown in the original study’s Table 4 {3}, shown here as figure 1. Though they took took over 10 years to plan and carry out, the three collaborative and harmonised international trials of ARISE (1600 patients in 51 oceanic hospitals, 2014), PROCESS (1351 patients in 31 American hospitals, 2014) and PROMISE (1260 patients in 56 UK hospitals, 2015) did not replicate the findings of the original Rivers trial – and the use of EGDT slowly waned {6 – 8}. In fact, today our practice can be characterised by avoidance where possible, of transfusions, central venous lines and invasive ventilation – the emphasis then became on early recognition, early intravenous fluids, and timely antibiotics. In 2016 the Third International Consensus Definitions for Sepsis and Septic Shock – colloquially known as Sepsis 3 – made some improvements {9}; they did away with severe sepsis – keeping only the categories of simple infection, sepsis, or shock, – they placed an emphasis on SOFA scores and de-emphasized SIRS criteria in diagnosis, and they provided a good definition for sepsis – “life threatening end-organ dysfunction that results from a dysregulated response to infection. However, what followed was the 2016 guidelines of the Surviving Sepsis Campaign and it’s now infamous 2018 update {10, 11}, which brought on an uproar by many clinicians who these guidelines applied to. Specifically, two strong recommendations were perceived as being mismatched with their supporting evidence: i) to rapidly administer 30mL/kg of crystalloid for any patient with hypotension or lactate ≥4mmol/L who was thought to be in septic shock. ii) a 1hour door-to-antibiotics times for any patient with sepsis. The first strong recommendation was challenged for the relative-lack of supporting evidence {12} as well as its potential to cause harm: titrating therapy to patient-centered parameters and clinical response is a more nuanced approach they may have better outcomes than rather large fluid boluses of pre-determined volumes {13}. The second strong recommendation was challenged for its feasibility as well as the relative-lack of supporting evidence {14}: though earlier antibiotics are associated with survival in septic shock, the link in sepsis without shock is more elusive, and differentiating sepsis from the bulk of simple infections that people acquire is a process that commonly takes longer than 1 hour, especially in access blocked and overcrowded emergency departments. Thus, we arrive at the current 2021 issue of the Surviving Sepsis Guidelines {15}, where antibiotics for possible sepsis carries a more reasonable recommendation of administration within 3 hours (timing for probable sepsis remains at <1hr), the advice for 30mL/kg of fluid was downgraded to weak strength and linked with dynamic measures to guide the fluid resuscitation, and norepinephrine (noradrenaline) was upheld as the first line vasopressor targeting a MAP of ≥66mmHg. PAPER ONE INTRODUCTION OF AN EMERGENCY MEDICINE PHARMACIST-LED SEPSIS ALERT RESPONSE SYSTEM IN THE EMERGENCY DEPARTMENT: A COHORT STUDY READ IT HERE CLINICAL QUESTION The stated aim of this study was to evaluate the impact of a sepsis performance improvement program in the ED with early involvement of an EM pharmacist. The stated key findings of the study relate to whether the above implementation reduced key performance indicators including time to antibiotics. JOURNAL Emergency Medicine Australasia, 2023 LEAD AUTHOR Christina Petronela Roman, EM Pharmacist DESIGN Single centre self-controlled prospective cohort study POPULATION 180 patients presenting to a metropolitan major referral hospital’s ED during pharmacist working hours, who were admitted to ICU with a diagnosis of sepsis. EXPOSURE Sepsis alert response system which includes an EM-pharmacist, from February 2016 to February 2018. COMPARISON Self-controlled parameters for patients admitted to ICU from ED with a diagnosis of sepsis from January 2015 to February 2016. OUTCOME Primary: Proportion of patients who received antibiotics within 60 minutes. Secondary Outcomes Proportion of patients completing the sepsis bundle within 60 minutes of arrival (fluid bolus, 2 blood cultures and serum lactate) FINDINGS Primary Outcome Proportion of patients receiving empiric antimicrobials improved from 26.3% to 81.7% (OR 12.6, 95% CI 6.2 – 25.4%, P<0.001). Secondary Outcomes Proportion receiving IV Fluids improved from 47.5% to 72.1% (P=0.002) Proportion receiving blood cultures improved from 52.5% to 85.6% (P<0.001) Proportion receiving a serum lactate improved from 50.0% to 66.9% (P<0.001) Secondary outcomes: No significant difference in pain at any measured time-point. No significant difference secondary outcomes in function questionnaires. Statistically significant difference in parent satisfaction on day 1 and analgesia use on day 1. While not statistically significant, trend for bandage group to be more likely to have used analgesia (except D1), and have missed school. AUTHORS' CONCLUSIONS The authors report that the implementation of a sepsis alert response that included early involvement of the EM pharmacist was associated with improvement in time to antimicrobials in the ED. BOTTOM LINE Due to the breadth of confounders in any time-controlled study, it is difficult to use this as evidence for a cause-effect relationship. However, it does seem that whether it was due to a sepsis alert response or whether it was due to a department continuously improving its KPIs (probably both), time to antimicrobials, fluids and serum lactate seem to have improved between 2015 and 2018. Limiting the subjects to only those admitted to ICU was wise (and probably the only feasible was to arrive at a comparator). This is because time to antibiotics is a more appropriate measure in patients with septic shock, and typically those are the patients with sepsis who require intensive care. This also then means that the conclusions of this study do not extend to patients who did not require ICU. In my anecdotal experience, the presence of EM pharmacist in this sepsis alert response is very helpful – they track previous sensitivities, help identify dose adjustments when required, can safely chart the medicines decided upon with the medical officer, and seem to act as an advocate in reducing time-to-intervention in patients with sepsis. However, this study cannot differentiate the EM pharmacist from the sepsis alert response itself – therefore even if the study design enabled us to draw a clear link between the sepsis alert response and times to intervention, drawing out the effect of the EM-pharmacist from the sepsis alert would then still need to be shown. Operational decisions cannot be limited to only that which has high quality evidence, and therefore until a feasible high-quality trial that isolates and demonstrates the effects of an EM pharmacist within a sepsis alert bundle is conducted, I suspect that we will continue to see our pharmacist colleagues supporting us in offloading some of the pharmacological cognitive burdens that often accompany these alerts. PAPER TWO RESTRICTION OF INTRAVENOUS FLUIDS IN ICU PATIENTS WITH SEPTIC SHOCK READ IT HERE CLINICAL QUESTION: What are the effects of a restriction of IV fluids on mortality and other outcomes in adult patients with septic shock in the ICU? JOURNAL The New England Journal of Medicine, June 2022 LEAD AUTHOR Tine Sylvest Meyhoff, MD DESIGN Open Label Prospective Multicentre RCT POPULATION 1554 patients ≥18 years of age who were admitted to ICU with suspected septic shock, as defined by suspected infection with lactate ≥2mmol/L, ongoing inopressors, and having received ≥1L IV Fluids within the prior 24 hrs. EXPOSURE Restrictive IV Fluid therapy for the following indications: Severe hypoperfusion => 250 – 500mL bolus lactate ≥4mmol/L, MAP <50mmHg despite inopressors, skin mottling score of ≥2 urine output <0.1mL/kg/hr Fluid Losses => Replace the same volume Dehydration / Electrolyte derangements => Correct the derangement Total daily fluid => Top up to target total daily fluid intake of 1L COMPARISON Standard / Unlimited IV Fluid therapy for the following indication Improve haemodynamic compromise Replace expected or observed losses Correct dehydration / electrolyte derangement Maintenance fluids as per local ICU protocol ACTUAL EXPOSURE VERSUS COMPARATOR Intravenous Balance             and                  Cumulative Fluid Balance D1: 1               vs 1.7 L            and                  +0.7L   vs +1.3L D5: 2.3            vs 3.8L             and                  +1.6L   vs +2.4L OUTCOME Primary: Death within 90 days post randomisation Secondary Outcomes Number of patients with ≥1 serious adverse event (CVA, MI, Mesenteric ischemia, or Limb ischemia. Number of patients with ≥1 serious advance reaction to IV crystalloid (Seizures, Anaphylaxis, osmotic demyelination, severe hypernatremia, severe hyperchloremic acidosis, or severe metabolic alkalosis). The number of days, at 90 days, where the patient wasn’t requiring life support or was alive and out of hospital. WHAT WERE THE FINDINGS? No difference in death at 90 days (42.3 vs 42.1 %, ARR 1.0, 90% CI 0.89 – 1.13). No statistically significant difference in any of the secondary outcomes AUTHORS' CONCLUSIONS There was no significant difference in 90-day mortality or serious adverse events among patients who received restricted fluid therapy and those who received standard therapy. CLINICAL BOTTOM LINE Technically this is an ICU trial, it therefore applies to ICU patients – not to ED patients, unless those patients are spending upwards of 12 hours in the ED. Don’t treat the algorithm, treat the patient. The lessons learnt over the past 30 years emphasize the avoidance of blanket interventions for all patients, instead emphasizing patient-specific clinical parameters – even the restricted arm of this trial factors lactate, skin mottling, blood pressure and urine output into the decision-making process. In deciding whether to give more fluids in Emergency Department patients with septic shock, we target MAP ≥65mmHg, CR <2, Conscious State, Urine Output and a point of care echo. The ED is certainly capable of providing good critical care (resuscitation), but it is not an ICU. When ICU patients spend ≥12 hours in the ED, change gears and use whatever good methodology your ICU teaches, I was taught to use FAST HUGS (Feeding, Analgesia, Sedation, Thromboprophylaxis, Head Up, Ulcer Prophylaxis and Glycaemic Management). PAPER THREE PERIPHERAL VASOACTIVE ADMINISTRATION IN CRITICALLY ILL CHILDREN WITH SHOCK: – A SINGLE CENTRE RETROSPECTIVE COHORT STUDY READ IT HERE CLINICAL QUESTION What were the characteristics of critically unwell children on peripherally administered vasoactive medicines? What were the characteristics of the associated extravasation injuries? JOURNAL Journal of Pediatric Critical Care Medicine, August 2022 LEAD AUTHOR Robert A. Levy, MD DESIGN Single-centre retrospective cohort study POPULATION 231 patients with peripheral vasoactive access (PVA) and 525 patients with central vasoactive access (CVA), aged 31 days to 18 years who required adrenaline, noradrenaline or dopamine in a quaternary PICU. EXPOSURE Inotropes and vasopressors administered through a PVA. COMPARISON Inotropes and vasopressors administered through a CVA OUTCOME No primary outcome was differentiated from the basket of outcomes studied. Anthropomorphic characteristics within the two groups Percentages of Primary Diagnoses and of Invasive Interventions Proportions and doses of the various inotropes and vasopressors received Proportion of the PVA patients who ultimately required a CVA Proportion of the PVA patients who experienced extravasation injuries WHAT WERE THE FINDINGS? Patients who initially received vasoactive medicines through a PVA were: older (10.3 vs 9.4 years, p = 0.003) and heavier (30.9 vs 25.3 kg, p = 0.001). more likely to have sepsis (40.3 vs 19.8 %, p < 0.001) more likely to have had the vasoactive medicines initiated at night (64.5 vs 50.5 %, p < 0.001), less likely to have been intubated (50.7 vs 82.7 %, p < 0.001), less likely to have received CPR (3.0 vs 8.0 %, p < 0.001) Spent fewer days in PICU (2.8 vs 5.8 days, p < 0.001) Had a lower mortality (19.0 vs 10.4 %, p < 0.001) 75% of the PVAs used were 20 or 22 gauge. 4 out of 231 had an extravasation event, all in the hand. 3 of those received antidotes (phentolamine or terbutaline), none suffered from rebound hypotension. Of Patients who initially received vasoactive medicines through a PVA, the 53.7% who went on to require a CVA were: Lighter in weight (26.8 vs 37.2 kg, p = 0.04) More likely to be intubated (63.7 vs 35.5 %, n < 0.001) Spent longer in PICU (3.8 vs 1.9 days, p < 0.001) Had a higher mortality (15.3 vs 4.8 %, p = 0.009) AUTHORS' CONCLUSION Initial use of vasoactive medicines through a PVA may be an appropriate option while evaluating the need for CVA. CLINICAL BOTTOM LINE This is informative data. It is particularly informative to see the low rate of extravasation in critically unwell children with 20- or 22-gauge cannulas. The characteristics of patients on vasoactive medicines through PVAs was different, they were older, more likely to have sepsis, and were typically less unwell than those who received CVAs – this is largely intuitive. When needing to start vasoactive medicines in children, one option is to initiate them peripherally – ideally through a high-quality cannula in a proximal vessel – whilst making a decision on the need for a CVA. REFERENCES Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992 Jun;101(6):1644-55. doi: 10.1378/chest.101.6.1644. PMID: 1303622. Levy, Mitchell M. MD, FCCP; Fink, Mitchell P. MD, FCCP; Marshall, John C. MD; et al. For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Critical Care Medicine 31(4):p 1250-1256, April 2003. | DOI: 10.1097/01.CCM.0000050454.01978.3B Rivers E, Nguyen B, Havstad S, et al. Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307. PMID: 11794169. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. doi: 10.1097/01.ccm.0000117317.18092.e4. Erratum in: Crit Care Med. 2004 Jun;32(6):1448. Dosage error in article text. Erratum in: Crit Care Med. 2004 Oct;32(10):2169-70. PMID: 15090974. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af. PMID: 23353941. ARISE Investigators. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371(16):1496-506 ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014 May 1;370(18):1683-93. doi: 10.1056/NEJMoa1401602. Epub 2014 Mar 18. Mouncey PR, Osborn TM, Power GS, et al. Protocolised Management In Sepsis (ProMISe): a multicentre randomised controlled trial of the clinical effectiveness and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock. Health Technol Assess. 2015 Nov;19(97):i-xxv, 1-150. doi: 10.3310/hta19970. PMID: 26597979; PMCID: PMC4781482. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287. PMID: 26903338; PMCID: PMC4968574. Rhodes, Andrew MB BS, MD, Evans, Laura E. MD, MSc, FCCM, Alhazzani, Waleed MD, MSc, FRCPC, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine 45(3):p 486-552, March 2017. | DOI: 10.1097/CCM.0000000000002255 Levy, Mitchell M. MD, MCCM, Evans, Laura E. MD, MSc, FCCM, Rhodes, Andrew MBBS, FRCA, FRCP, FFICM, MD. The Surviving Sepsis Campaign Bundle: 2018 Update. Critical Care Medicine 46(6):p 997-1000, June 2018. | DOI: 10.1097/CCM.0000000000003119 Marik PE, Byrne L, van Haren F. Fluid resuscitation in sepsis: the great 30 mL per kg hoax. J Thorac Dis. 2020 Feb;12(Suppl 1):S37-S47. doi: 10.21037/jtd.2019.12.84. PMID: 32148924; PMCID: PMC7024756. Marik PE, Malbrain M. The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL per kg fluid! Anaesthesiol Intensive Ther 2017;49:323-8. 10.5603/AIT.a2017.0056 Sterling SA, Miller WR, Pryor J, et al. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Crit Care Med. 2015 Sep;43(9):1907-15. doi: 10.1097/CCM.0000000000001142. PMID: 26121073; PMCID: PMC4597314. Evans, Laura, Rhodes, Andrew, Alhazzani, Waleed, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine 49(11):p e1063-e1143, November 2021. | DOI: 10.1097/CCM.0000000000005337Danny is an Emergency Medicine Registrar at the Emergency and Trauma Centre and the current Senior Registrar for research. He trained in regional NSW before moving back to Melbourne to complete his training at the Alfred. DR DANNY MARHABA Emergency Registrar Danny is an Emergency Medicine Registrar at the Emergency and Trauma Centre and the current Senior Registrar for research. He trained in regional NSW before moving back to Melbourne to complete his training at the Alfred.

There is an urgency to support Australian ED clinicians with real‐time tools as the COVID‐19 pandemic evolves. The COVID‐19 Emergency Department (COVED) Quality Improvement Project has commenced and will provide flexible and responsive clinical tools to determine the predictors of key ED‐relevant clinical outcomes. The COVED Project includes all adult patients presenting to a participating ED and meeting contemporary testing criteria for COVID‐19. Outcomes measured include being COVID‐19 positive and requiring intensive respiratory support. The dataset has been embedded in the Electronic Medical Record and the COVED Registry has been developed. Regression methodology will be used to generate clinical prediction tools. This project will support EDs during this pandemic. For full details regarding this project and to read and download further information, click to read more. Listen to the first two episodes of the COVED podcast below: COVED_0 https://learning.emergencyeducation.org.au//opt/bitnami/apps/wordpress/htdocs/wp-content/uploads/2020/05/Podcast_COVED_0.mp3 COVED_1 https://learning.emergencyeducation.org.au//opt/bitnami/apps/wordpress/htdocs/wp-content/uploads/2020/05/COVED_1.mp3

The COVID-19 pandemic will stretch hospital resources all over the world. This guideline is a framework for all Emergency Departments to work from as we plan and respond to the pandemic. With our states, countries, metropolitan, rural and regional emergency care facilities all at different stages of community impact, and with markedly different workforce, infrastructure and resources available, local implementation of these guidelines will differ. However, there are general principles of COVID-19 and non-COVID-19 emergency care that will apply to all workplaces: There is no patient emergency more important than the safety of our healthcare workforce. Appropriate, judicious use of personal protective equipment (PPE) is paramount. Planning for the increased numbers of patients requiring critical care services is important. Special consideration should be given to vulnerable people, both patients and staff, such as those who are older or have comorbidities, as well as Indigenous populations. Read and download the guideline on the ACEM website

The COVID-19 pandemic will stretch hospital resources all over the world. Emergency Departments (EDs) in high-income countries are vulnerable, but those in low and middleincome countries are likely to be impacted more significantly. Developed by the Australasian College for Emergency Medicine (ACEM), this guide provides consensus-based advice on how to optimise resources during the pandemic. The information is structured into four components: Systems Space Supplies Staff The information in this guide is generic in nature, and will not be applicable to every ED. Although the guide references technical guidance from the World Health Organization (WHO), local guidelines and procedures should be followed wherever they exist. Download the guide: Managing Covid-19 across the Indo-Pacific Visit the ACEM website for more Covid-19 Resources

In this Rapid Review, we look at decision making around the intubation of patients with Covid-19. This training provides modifications to intubation, designed to achieve first attempt intubation without aerosolisation. The video will take you through: Role allocation Preparation for RSI outside the room including: Equipment Personal protective equipment Drugs Preparation for RSI inside the room including: Preoxygenisation Intubation Post intubation Click here to watch the video. Total duration 6:54

Screening and Management of BCVIs in blunt trauma patients Dr Luke Phillips Emergency Consultant Video Content: Dr Barry Cunningham Peer Reviewer: Dr David McCreary A 60yo M presents to the trauma centre after his 4WD vehicle collided with a semi-trailer at 90km/hr. He was entrapped in the vehicle for more than 1 hour. At scene he has an unrecordable blood pressure and has had bilateral finger thoracostomies. He has received 4 units of blood en-route. On arrival to the ED he has suspected chest and head injuries and a large bore MAC line is inserted into his left subclavian vein, a massive transfusion protocol is commenced, chest drains inserted and upon stabilisation he is intubated for transfer to CT for a pan scan. En-route the ED registrar asks if we should image his carotid arteries to exclude a carotid injury? Having recently completed a senior registrar rotation through the Alfred Trauma service, Dr Barry Cunningham presented this lightning learning on BCVI to our registrars at their weekly teaching session. Blunt Cerebrovascular Injury (BCVI) is a non-penetrating injury to the carotid and/or the vertebral arteries. Motor vehicle accidents are the most common cause however we do see patients with BCVIs who fall, have sports related injuries or strangulations. It is caused by either a stretching or impingement of the vessel wall with forceful movements of the head and neck during an acute injury. This can be from a direct blow, hyperextension with rotation, skull base fracture involving the carotid canal or blunt intra-oral trauma.  An intimal tear is formed with exposure of the sub-intimal layers to blood products and either a thrombus, pseudoaneurysm, wall haematoma or vessel occlusion can occur. Figure: Traumatic cerebrovascular injuries. A, Intimal disruption. B, Intimal disruption with thrombus formation. C, Elastic laminae disruption allowing traumatic aneurysm formation (arrows). D, Hematoma within the artery wall with luminal stenosis. (Harrigan et al (2020)) BCVI is associated with poorer predicted outcomes and higher morbidity and mortality in trauma patients. A significant number of patients go onto suffer strokes during their inpatient stay or have a stroke pre-hospital. It is a commonly missed injury as it typically has a latent period between the time of injury and onset of symptoms. CT angiography of the neck is the current imaging modality of choice ALFRED BCVI CRITERIA (based on Modified Denver  Criteria)Clinical:Imaging: Seat belt or other abrasion of neck C1- C3 Cervical spine fracture, subluxation or ligamentous injury Cervical haematoma or bruit Fracture through foramen transversarium Scalp de-gloving Mandibular Le Fort II & III fractures Arterial haemorrhage from wound / mouth / nose / ears Base of skull fracture involving carotid canal Unexplained neurological deficit including GCS ≤8 Acute infarction on CT brain Horner’s syndrome and TIAs associated with blunt trauma Closed head injury with diffuse axonal injury Severe chest injuries Sternal or 1st/2nd rib fractures Carotid Angio CT if ≥1 positive criteria Grading of BCVIGradeFindingImplicationIluminal irregularity or dissection with <25% luminal narrowing 3% stroke rate 7% chance of  progressionIIdissections with ≥25% luminal narrowing, intraluminal thrombus, or a raised intimal flap70% risk of progressionIIIpseudoaneurysmtend to persistIVcomplete occlusion44% stroke rateVtransection of the carotid artery with free extravasation of contrast or significant AV fistula100% mortality C-spine immobilisation for 2-3weeks Antithrombotic treatment Grade I BCVI dissections are treated with aspirin 300mg loading dose followed by 100mg daily initially. Grades II-IV should be treated with either antiplatelet therapy or intravenous heparin – APTT target 50-60 sec depending on the perceived risk of clot propagation against embolization. If there is intracranial involvement of the dissection, then anticoagulation should be avoided and aspirin 100mg daily should be administered. Any initiation of antithrombotic treatment needs to be individualised and take into consideration other aspects of a patient’s traumatic injuries and general medical condition. Endovascular Stents +/- Thrombolysis (rare) Surgical (rarer) Key References: Biffl WL, Cothren CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma 2009;67:1150–53 doi:10.1097/TA.0b013e3181c1c1d6 PMID:20009659 Kim DY, Biffl W, Bokhari F, Brakenridge S, Chao E, Claridge JA, Fraser D, Jawa R, Kasotakis G, Kerwin A, Khan U, Kurek S, Plurad D, Robinson BRH, Stassen N, Tesoriero R, Yorkgitis B, Como JJ. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. (2020) The journal of trauma and acute care surgery. 88 (6): 875-887. doi:10.1097/TA.0000000000002668 - Pubmed Cothren CC, Moore EE, Ray CE, Johnson JL, Moore JB, Burch JM. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. (2007) Surgery. 141 (1): 76-82. doi:10.1016/j.surg.2006.04.005 - Pubmed Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. (2012) The journal of trauma and acute care surgery. 72 (2): 330-5; discussion 336-7, quiz 539. doi:10.1097/TA.0b013e31823de8a0 - Pubmed Brommeland, T., Helseth, E., Aarhus, M. et al. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med 26, 90 (2018). https://doi.org/10.1186/s13049-018-0559-1 Alfred Guidelines for the Investigation and Management of BCVIs (2019) Harrigan MR. Ischemic Stroke due to Blunt Traumatic Cerebrovascular Injury. Stroke. 2020 Jan;51(1):353-360. doi: 10.1161/STROKEAHA.119.026810. Epub 2019 Dec 11. PMID: 31822250. Luke is an Emergency Physician at Alfred Health in Melbourne and is currently the co-ordinator for point of care ultrasound education within the department. Luke has a special interest in the use of ultrasound for critically unwell patients, in trauma management and in the use of ultrasound to guide procedures and improve patient safety in the ED. In addition to ultrasound, Luke has developed a Certificate of Emergency Medicine for the Alfred Emergency and Trauma Centre’s International Program and also has special interests in airway management and simulation. Luke is the creator and editor of the open access education website and blog – pocusgeelong.com, a reviewer for the POCUS section for Life in the Fast Lane weekly review and an instructor with Ultrasound Training Solutions in Melbourne. Luke is currently a Co-Chair of the Victorian branch of the Emergency Medicine Ultrasound Group (EMUGS) and has completed a number of CCPU units through ASUM. His twitter handle is @lukemphillips