ASEM Best Paper Prizes 2009

"The CO2 GAP Project – CO2 GAP as a Prognostic Tool in Emergency Departments"

Authors: Shetty: A1, Lai: K2, Byth: K3
1. Westmead Hospital, Sydney, NSW
2. Westmead Hospital and Nepean Hospital, Sydney, NSW
3. Westmead Millenium Research Institute, Sydney, NSW

Background: Capnography has been recommended for monitoring severity of pulmonary disease and evaluating response to therapy, especially therapy intended to improve the ratio of dead space to tidal volume (VD/VT) and the matching of ventilation to perfusion (V/Q), and possibly, to increase coronary blood flow. CO2 GAP is known to be a marker for dead space and V/Q mismatching and responds to changes in cardiac output.

Objective: Prospective Observational study to determine if CO2 GAP can be used as a prognostic tool to predict need for assisted ventilation in patients presenting with shortness of breath (SOB) to emergency department (ED).

Methods: 412 patients underwent concurrent ABG and ETCO2 measurements in ED as part of management of SOB. CO2 GAP and A-a gradient results were derived from these readings and matched to assisted ventilation outcomes and admission to High Dependency Unit/ Intensive Care Unit or death in ED.

Results: 27.2% of patients required assisted ventilation and 35.2% were either admitted to HDU/ICU or died in the training set of cohort. Analysis of the Receiver Operator Characteristics curves revealed the CO2 GAP performed significantly better than the A-a gradient in predicting worse outcomes (AUC 0.950 vs. 0.726). A CO2 GAP > 10.5 predicted need for assisted ventilation outcomes when applied to the validation test set with 100% sensitivity.

Conclusions: The CO2 GAP may have a prognostic role in predicting need for assisted ventilation outcomes in emergency departments in patients presenting with shortness of breath.

"The Alfred Hospitals Emergency Department Response as H1N1 (Swine Flu) Gripped Victoria"

Authors: J Thompson1 C Batey1, S Borrell2, L Houston2, G Land2, P Bass2, A Lickliter2, K Watson2, C. Stansfield2, G Harrington2
1. Emergency Department, Alfred Health
2. Infection Control and Hospital Epidemiology Unit, Alfred Health

On the 11th of June 2009, the World Health Organization declared the start of the 2009 Influenza pandemic. By definition the virus had spread rapidly around the world causing sustained community outbreaks in more than one WHO region. WHO reported that this is the first such strain of virus to reach this level in 41years. To date there have been nearly 30,000 cases with 74 countries reporting confirmed cases. As of the 11th June 2009 the national breakdown for Australia of confirmed cases was WA with 29 cases, NT with 7, Tas with 13, ACT with 17, SA with 17, Qld with 68, NSW with 101 cases and Victoria with 1011 cases.

As the numbers continued to rise in Victoria patients began to present to hospital Emergency Departments(ED) across Melbourne the Human Services Department moved to established dedicated flu clinics in the community. The Alfred Hospital in liaison with the Human Services Department acted quickly with a decision by our Pandemic Working Group in late May to run an ED assessment service.

Using infection control principles of clean and contaminated zones ED staff determined designated zones in ED and the annex along with developing procedures to allow for patients presenting to ED with a flu like illness to a) be screened at the entrance to ED prior to progressing to ED triage and the ED waiting room, c) triaged to the annex for medical assessment or c) triaged to a negatively ventilated room in the ED for medical assessment and d) escorted to the annex wearing appropriate personal protective Equipment (PPE).

The purpose of this presentation is to outline the logistics and planning required to setting up, stocking and staffing (voluntary and exclusion of high risk staff) the annex along with developing annex procedure guidelines and the impact this has had on day to day operations of a major metropolitan Emergency and Trauma Centre. The importance of interdepartmental relationships and the role Infection Control staff have in such a crisis will also be discussed.

SSEM 2010


"Is paracetamol testing necessary on every patient who presents to the ED following an overdose?

Matthew Clarke ACEM 4:10 project

Introduction: Screening all patients presenting to Australasian Emergency Departments (EDs) with deliberate self poisoning for paracetamol ingestion is common practice but results in many negative tests and can be time consuming. There have been a number of studies in the USA, Hong Kong and most recently the UK showing that the number of patients with a history negative for paracetamol ingestion and positive blood results on screening is low. Hartington et al proposed a clinical decision rule (CDR): In patients who have taken a deliberate overdose, but deny taking paracetamol containing products, who have a GCS of 15, understand English well, and have not taken excessive alcohol, there is no need to take blood for paracetamol estimation. This rule has not been tested in an Australasian population.

Objectives: To describe the characteristics of patients presenting to our ED with overdose, focussing on patients with paracetamol poisoning and to evaluate whether all patients with overdose require paracetamol levels by determining the false negative rate for the paracetamol overdose CDR described by Hartington et al.
Methods A retrospective chart review and a prospective audit of all patients presenting to the ED in Whangarei Hospital, New Zealand.

Results: A total of 352 presentations with deliberate drug overdose were reviewed retrospectively. Paracetamol was ingested in 28.4% of presentations with overdose. Females made up 64.6% of the presentations with overdose. The age range for presentations was 13 to 81, with the average age of 32.3 years. The average number of drugs ingested was 1.93, ranging from 1 drug to 9 drugs. Of the 668 drugs ingested in 345 presentations, analgesics were ingested 60% of the time, sedatives 38% of the time, antidepressants 34% of the time, antipsychotics 23% and anti-epileptics 11% of the time. Out of 345 presentations there were 91 admissions to hospital (26% admission rate) for medical reasons and 25 of those (7.2%) were admitted to the Intensive Care Unit. There were 14 patients who were history of paracetamol ingestion negative and CDR positive and who had detectable levels of paracetamol. There were 10 patients who were history of paracetamol ingestion negative and CDR negative who had detectable levels of paracetamol.

The false negative rate from my retrospective audit is 1/75, 1.3% (95% C.I. 0.24% - 7.2%).
The prospective arm of the audit ran between 01/04/2008 and finished on 30/09/2008. It yielded 31 presentations. One person died in the CDR positive arm of the study.

Discussion: The rate of paracetamol ingestion in overdose presentations was above the rate reported in previous studies. The upper 95% CI (7.2%)of the retrospective audit false negative rate suggests an unacceptably high level of risk of missing serious paracetamol poisoning using Hartington et al’s CDR in this population. Other findings of note were the number of presentations where no blood tests were performed, the number of paracetamol levels taken before the 4 hour mark and the number of people who denied ingesting paracetamol with positive blood levels.

Darwin Winter Symposium 2009

"A Comparison of Novel Cooling Methods for Prevention of Hyperthermia in CBR Responders in the 'Top End' of Australia"

Hrabar KD1, Norton I1, 2, Brearley M3, Trewin T4, Mitchell C1
1. Royal Darwin Hospital, Darwin, Australia
2. National Critical Care + Trauma Response Centre, Darwin, Australia
3. Northern Territory Institute of Sport, Darwin, Australia
4. Northern Territory Fire and Rescue Service.

Aims: To assess the physiological and perceptual responses of health care workers to a CBR (chemical, biological, radiological) training exercise in tropical 'wet season' conditions, and to compare the effectiveness of four cooling methods.

Methods: 60 volunteer participants, all of women were health care workers (predominately doctors and nurses) were randomised into 4 cohorts (1 Shade; 2 Ice Vest; 3 Water Immersion; 4 Crushed Ice Ingestion) matched for body mass index (BMI). The exercise consisted of triaging, resuscitating, mobilising and decontaminating manikins while dressed in level 3 PPE (personal protective equipment) in field conditions (mean outdoor wet-bulb globe temperature of 31.4 degrees celsius) for 30 minutes followed by removal of the PPE for 30 minutes of cooling; repeated 3 times. Cohort 2 wore ice vests under their PPE during the active phase, and then rested in the shade. During the cooling phase, cohort 1 rested quietly in the shade, cohort 3 were immersed in large tubs of water at 25 degrees celsius and cohort 4 ingested body mass of crushed ice. All 4 groups had ad libitum access to fluids. An ingestible telemetry pill permitted measurement of core temperature throughout exercise, while tympanic temperature, heart rate, blood pressure, subjective thermal sensation and thermal discomfort ratings were recorded periodically throughout the cooling phase.

Results: The peak core body temperature of 40.8 degrees celsius was observed, with a total of 3 participants recording temperatures above 40.4 degrees celsius during the study. Overall, the participants that wore the ice vests during the active phase and those that undertook water immersion during the rest phase stored less heat during their active phases. Subjectively, participants found the water bath to be the most effective and appealing method of cooling.

Conclusions: This study, the first of its kind, was carried out in tropical conditions in the field, with health care workers wearing impermeable PPE during a realistic CBR incident scenario. We confirmed that CBR responders are at risk of hyperthermia in these conditions. We also sought to find a safer means of allowing responders to work for sustained periods in the heat if required, and concluded that the use of water baths and ice vests for active cooling were options with great potential.

Queensland Autumn Symposium, April 2009

"The Outcome of Patients with Sepsis Syndrome Admitted from the Emergency Department"

Author: Williams J, McKenzie J, Greenslade J, CHu K, Brown AFT Royal Brisbane and Women's Hospital, Brisbane, Queensland

Background: The majority of data on the outcome of patients presenting to hospital with sepsis has been derived from ICU based studies and has shown a high mortality rate. Prospective data on the proportion of patients within the different sepsis subgroups and their outcomes in the Australian setting is not well known. We sought to determine the outcome for the various sepsis subgroups (infection with and without SIRS, severe sepsis and septic shock) admitted through ED and to identify possible candidates for EGDT (Early Goal Directed Therapy).

Methods: We conducted a prospective observational cohort study in an Australian tertiary adult hospital ED. Patients admitted through the ED with a diagnosis of infection were identified and data was abstracted from patient charts and electronic databases.

Results: 1846 patients were included over a 43 consecutive week period. Patients from the subgroups infection without SIRS, sepsis, severe sepsis and septic shock comprised 45.7%, 36%, 13% and 5.4% of the total cohort respectively. The in-hospital mortality of these subgroups was 1.2%, 3.3%, 10.4% and 21.2%. The OR of 30 day mortality for 2 or more SIRS criteria was 2.21. Of our total patients, 73 (4%) would have been eligible for EGDT.

Conclusion: Our mortality rates for patients with severe sepsis and septic shock were lower compared to recent similar studies. The presence of 2 or more SIRS criteria on admission to ED was found to be of prognostic significance. The proportion of possible EGDT candidates was higher in comparison to other Australian studies.

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