Showing papers in "Emergency Medicine Australasia in 2003"

Comparison of a verbal numeric rating scale with the visual analogue scale for the measurement of acute pain

Abstract: Objectives: To test the agreement between the visual analogue scale (VAS) and a verbal numeric rating scale (VNRS) in measuring acute pain, and measure the minimum clinically significant change in VNRS. Methods: Patients scored their pain by the VAS and the VNRS, then re-scored their pain every 30 min for up to 2 h. Patients also recorded whether their pain had improved or worsened. Agreement between scores was evaluated, and where patients scored their pain as ‘a bit worse’ or ‘a bit better’ the mean change in VNRS was calculated. Results: A total of 309 paired observations were obtained from 79 patients. The VAS and VNRS were highly correlated (r = 0.95, 95% CI 0.94–0.96). The VNRS was significantly higher than the VAS for the paired observations, with 95% of the differences between VAS and VNRS lying between −2.3 and 1.3 cm. The minimum clinically significant difference in VNRS was 1.4 cm (95% CI 1.2–1.6). Conclusions: The VNRS performs as well as the VAS in assessing changes in pain. However, although the VAS and VNRS are well correlated, patients systematically score their pain higher on the VNRS, with an unacceptably wide distribution of the differences.

Unethical practices in authorship of scientific papers.

Abstract: Over the past few decades, there has been an increase in the number of multi-author papers within scientific journals. This increase, in combination with the pressure to publish within academia, has precipitated various unethical authorship practices within biomedical research. These include dilution of authorship responsibility, 'guest', 'pressured' and 'ghost' authorship, and obfuscation of authorship credit within by-lines. Other authorship irregularities include divided and duplicate publication. This article discusses these problems and why the International Committee of Medical Journal Editors guidelines are failing to control them.

Hospital and emergency department crowding in the United States

Abstract: Every emergency physician in the United States and, for that matter, in many countries around the world recognizes that the demand for timely access to quality emergency care is one that patients highly value. Unfortunately, hospitals in the USA have become stretched beyond capacity, resulting in overloaded emergency departments, diverted ambulances, and greater risks for patients and providers. Some of the causes and consequences of emergency department crowding are unique to the USA health care system, while others are common to countries throughout the world. The goals for this paper are to provide a brief overview of hospital and emergency department crowding in the USA, to identify commonly cited causes of the problem, and to outline future directions in the search for solutions. A large number of hospitals, inpatient beds, and emergency departments have closed during the past 10 years in the USA. In 1992 there were around 6000 hospitals with emergency departments and there are now less than 4000. While hospitals scrambled to decrease an excess supply of inpatient beds, the demand for emergency department care steadily rose. Between 1992 and 2000, the annual number of emergency department visits in the USA increased from 89.8 to 108 million. While some areas of the USA have been affected more seriously than others (particularly the coasts), almost every state has reported problems with boarding of inpatients in the emergency department. Inpatient boarding is the most frequently cited reason for emergency department crowding within the emergency medicine community. United States hospitals are also struggling with a shortage of health care professionals, particularly registered nurses. There are several policy issues that must be addressed to alleviate hospital and emergency department crowding over the long term. We list these as 'long-term' goals simply because policy changes, in the USA, are often incremental and rarely occur quickly. In order to achieve any of these changes in policy over the long term, advocates for reform must aggressively pursue them today.

The heaviest repeat users of an inner city emergency department are not general practice patients.

Abstract: Objective: To test the hypothesis that frequent attenders to the ED are suitable for diversion to general practice. Methods: A retrospective review of a computerized database for the top 500 frequent presenters to an inner city adult teaching hospital ED. Results: Five hundred patients presented 12 940 times, an average of 26 times per patient, accounting for (8.4% [8.3, 8.6] ) of total ED presentations over 64 months. There were 7699 (59.5% [58.7, 60.4] ) presentations deemed appropriate for ED. Of the remaining 5241 presentations, 1553 (29.6% [28.4, 30.9] ) were between 22.00 and 07.00 hours, outside the hours of most actual or proposed primary care clinics. This left 3688 (28.5% [27.7, 29.3] ) presentations by the heaviest users of the ED as potentially appropriate for general practice. Of these presentations 1507 (40.9% [39.3, 42.5] ) were by people who were homeless. A total of 2574 (69.8% [68.3, 71.3] ) had pre-existing case management, either by the hospital or another service. Nine hundred and seventy-eight (26.5% [25.1, 28.0] ) had primary psychiatric or altered conscious states due to drugs and alcohol as the presenting problem. At least 90 of these 500 frequently presenting patients died during the study period. Conclusion: The majority of the presentations by the heaviest users of an ED in a city teaching hospital are not suitable for general practice. Attempting diversion of the heaviest repeat ED users to a general practice in this setting may not be successful due to the severity, acuity and nature of casemix of the presentations and would have minimal impact on crowding in similar emergency departments.

Reduced access block causes shorter emergency department waiting times: An historical control observational study.

Abstract: Objective: To study the effect of changes in hospital occupancy and ED occupancy on ED waiting times during a 13-day period of improved bed access. Methods: A comparative, observational study of 1133 ED attendances in the study period and 2332 attendances in a historical control period. Results: During the study period, mean hospital occupancy decreased from 94.9% to 89.0% (P < 0.001), mean ED occupancy decreased from 19.1 to 14.8 patients (P < 0.001) and the mean ED waiting time decreased from 58.5 to 37.1 min (P < 0.001). There were statistically significant reductions in waiting times for patients in Australasian triage scale (ATS) categories 2–5. Departmental staffing levels, attendances and patient acuity were not significantly different during the study and control periods. Conclusions: Modest decreases in hospital occupancy resulted in highly significant reductions in ED waiting times. Emergency department overcrowding due to large numbers of admitted patients awaiting hospital admission is a major cause of ED dysfunction.

The status of the Glasgow Coma Scale

Abstract: The Glasgow Coma Scale (GCS) was first introduced in the 1970s to provide a simple and reliable method of recording and monitoring change in the level of consciousness of head injured patients. Since its introduction, the GCS has been widely utilized in the trauma community and its use expanded beyond the original intentions of the score. In the context of traumatic injury, this paper discusses the use of the GCS as a predictor of outcome, the limitations of the GCS, the reliability of the GCS and potential alternatives through a critical review of the literature. The relevance to Australian trauma populations is also addressed.

The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage.

Abstract: The Canadian Triage and Acuity Scale has received widespread acceptance in Canada as a reliable and valid tool for emergency department triage. The importance of accurate triage becomes more apparent as emergency department volumes increase, and resources shrink. The need to ensure that those patients requiring more urgent care receive care first is the basis for all triage scales. Through the Canadian Triage and Acuity Scale National Working Group, the scale became the recommended triage tool for Canadian emergency departments. Work has been done on the interrater reliability of Canadian Triage and Acuity Scale among health care providers. There is a need to further assess the validity of the scale. This scale has now been applied in the out of hospital setting by paramedics and is being used in measurements of emergency physician workload. The future may see an electronic triage tool develop for emergency department use to reduce variability in its application. The Canadian Triage and Acuity Scale has become an integral component of Canadian emergency departments.

Buffering the pain of local anaesthetics: A systematic review.

Abstract: Objective: To review the evidence that buffering of local anaesthetics with sodium bicarbonate reduces the pain of injection whilst not affecting efficacy. Methods: Medline search from 1966 to December 2001. Articles in all languages were included. Bibliographies were examined for papers. Results: The search identified 63 publications. All were retrieved. Of these, 22 were human prospective randomized controlled trials directly assessing the pain of infiltration. Three papers were based on observations. No case series, case reports, or retrospective studies were identified. One animal study was found. Conclusion: The evidence is that buffering with sodium bicarbonate significantly reduces the pain of local anaesthetic injection. The buffered solutions retain the efficacy of local anaesthetics and are stable in the mixtures used in the trials. Adrenaline-containing buffered solutions need refrigeration in closed containers for storage. Buffering will be particularly useful where pain of local anaesthetic injection may not be well tolerated such as in large areas of infiltration, sensitive areas such as the face and in children. It is recommended that sodium bicarbonate and tables of stable dilutions are readily available in the emergency department to facilitate this.

Documentation and tagging of casualties in multiple casualty incidents.

Abstract: The use of triage tags is widely advocated as a tool to improve the management of multiple casualty incident scenes. However, there are no published reports to suggest that triage tags have improved the management of incidents involving more than 24 persons, and a number of reports have detailed problems associated with triage tag use. Alternative systems of scene management such as geographical triage have been successfully used in very large incidents, and are recommended as an alternative to triage tags. Documentation cards attached to casualties may be of use in situations where casualties will pass through an extended evacuation chain, and clear labels for deceased casualties are of benefit as they discourage repeat assessments. Adoption of an evidence-based approach to multiple casualty incident scene management will require a paradigm shift in the thinking of ambulance services. A broad-based educational approach that encourages critical reappraisal of existing procedures is recommended.

Impact of SARS on an emergency department in Hong Kong.

Abstract: Objective: To report on the impact of a Severe Acute Respiratory Syndrome (SARS) outbreak on the attendances of a major teaching hospital ED. Methods: Two periods were studied. The first was prior to the closure of the ED due to SARS and the second was after re-opening of the ED. Data on attendances, discharge against medical advice, triage categories, trauma and ambulance cases were retrieved from the computer and compared with the data in the same periods in 2002. Results: In the first period, when compared with 2002 there was a significant decrease in the mean daily attendance (397 vs 524), trauma cases (68 vs 111), minor cases (category 4: 283 vs 361, and category 5: 20 vs 43). In the second period, there was a significant decrease in the mean daily attendance (265 vs 545), trauma cases (40 vs 111), minor cases (category 4: 181 vs 376, and category 5: 12 vs 45), discharge against medical advice (4 vs 6 daily) and ambulance cases (70 vs 86 daily). Patients requiring immediate care however, remained similar. Conclusion: There was a significant drop in the overall ED attendance, trauma cases and minor cases after the outbreak of SARS. Possible causes include changes in community behaviour, resulting in a lower incidence of trauma and disease and fear of presenting to hospital and contracting SARS.

A strategic plan for disaster medicine in Australasia.

Abstract: Disaster epidemiology reveals epidemic increases in incidence of disasters. Rare disasters with catastrophic consequences also threaten modern populations. This paper profiles natural disasters, transportation incidents, emerging infectious diseases, complex disasters and terrorism for their historical and future potential impact on Australasia. Emergency physicians are in a position to assume leadership roles within the disaster management community in Australasia. The Australasian College for Emergency Medicine is in a position to lead medical specialty advances in disaster medicine in Australasia. To optimize its impact in disaster medicine, the specialty and its College have opportunities for advances in key areas of College administration, intra and interinstitutional representation, disaster preparedness and planning, disaster relief operations, education and training programs, applied clinical research, and faculty development.

Mechanisms of motor vehicle accidents that predict major injury.

Abstract: OBJECTIVE: To assess whether prehospital triage guidelines, based on mechanistic criteria alone, accurately identify victims of motor vehicle accidents (MVA) with major injury. METHODS: Retrospective analysis of the Royal Melbourne Hospital trauma database. Mechanisms analysed were those outlined by the American College of Surgeons Committee on Trauma and Advanced Trauma Life Support/Early Management of Severe Trauma prehospital triage guidelines. RESULTS: There were 621 MVA analysed, 253 with major injury (40.7%). Multivariate logistic regression indicated prolonged extrication time (P Language: en

Estimation of the general practice workload of a metropolitan teaching hospital emergency department.

Abstract: Background: A transparent and easily replicated method of estimating the number of, and costs associated with, low acuity presentations to an emergency department is required to assist evaluation of the utilization of emergency department services. This study presents two independent estimates of the number of, and costs associated with, low acuity presentations to an emergency department. Methods: A retrospective analysis was conducted using emergency department information system data from a metropolitan mixed paediatric/adult teaching hospital emergency department/trauma centre. Low acuity patient presentation estimates were calculated by: Method one: The product of (A) total self-referred presentations for triage categories three, four and five and (B) the difference between the self-referred and general practitioner-referred discharge rates from the emergency department. Total low acuity patient presentations = (A × B). Method two: Summing the number of self-referrals with presenting problems never referred by general practictioners. Costs were calculated using Commonwealth cost weights. Results: Method one gave a low acuity patient estimate of 12.5% (95% CI 12.0–13.0%) and method two 10.6% (95% CI 10.2–11.0%) of total presentations. Costs were 10.5% (method one) and 8.5% (method two) of total costs. Adjusted for assessment time, costs were 6.8% (method one) and 5.5% (method two) of total costs. Low acuity patients were more common outside of normal working hours, method one: 14.4% (95% CI 13.5–15.2%) versus 10.0% (95% CI 9.4–10.6%), P < 0.001; method two: 11.4% (95% CI 10.9–12.0%) versus 8.5% (95% CI 7.8–9.2%), P < 0.001. Provision of alternative daily 0900–2400 general practice services would change low acuity patients by no more than 2–3% of total presentations and change low acuity patient costs by no more than 2% of total costs. Conclusions: Low acuity patients form a small, relatively constant part of the emergency department workload. The provision of alternative after-hours services for low acuity patients would be unlikely to significantly reduce the overall work load of this metropolitan emergency department.

Giving a voice to the community: a qualitative study of consumer expectations for the emergency department.

Abstract: Objective: To identify consumer expectations with respect to the ED. Methods: Semi-structured focus groups comprising representatives from a wide range of community groups. Data was analysed using a qualitative analytical approach. Results: The major themes of the groups were communication, triage, waiting area, cultural issues and carers. Consumers expressed the need to be informed about how the ED functions, particularly with regard to the triage process, patient assessment and admissions procedure. Privacy at the triage desk, comfort and safety of the waiting area, provision of facilities for children, cultural awareness of staff, access interpreter services and recognition of the needs of carers were identified as key issues. Conclusion: The recognition of consumer needs provides the opportunity for the ED to develop strategies to match patient needs to service delivery.

Ketamine: its use in the emergency department.

Abstract: Ketamine has been known to the medical world for over 30 years, yet is not widely used to its full potential. It is often considered to be a 'third world' drug only. In light of a recent increase in interest in its use in the developed world, this review is for emergency physicians to use as a quick reference.

Spectrum of acute allergic diseases in an emergency department: an evaluation of one years' experience.

Abstract: Objective: There is limited available literature on the incidence of allergic diseases in ED. The objective of this study was to investigate the clinical records of patients admitted to the ED with a suspected allergic reaction. Methods: A 1 year retrospective study was carried out and data were collected from the patients’ computerized medical reports. Results: A total of 324 patients were admitted for an allergic event. Of those, 165 patients (50.9%) were female and their mean age was 55 ± 18.5 years. Diagnoses included: asthma in 100 patients (30.9%); hymenoptera allergy in 78 patients (24.1%); food allergy in 31 patients (9.5%); drug allergy in 25 patients (7.7%); and allergic conjunctivitis in 12 patients (3.7%). No diagnosis was found in the medical records of 78 patients (24.1%). Anaphylactic shock was observed in 12 patients (3.7%) with a diagnosis of food allergy (six cases), drug allergy (three cases) and hymenoptera allergy (three cases). Ninety patients (27.7%) were hospitalized in the following units: 38 in allergy unit (42.2%); 20 in intensive care unit (22.2%); 10 in pulmonary unit (11.1%); eight in the dermatology unit (8.9%); six in the internal medicine unit (6.7%); and eight in other units (8.9%). Overall, 42 patients (12.9%) were evaluated by an allergologist after ED discharge with positive allergy results in 28 cases (66.6%). Conclusions: Acute allergic diseases are not rare in ED, representing 1% of the annual visits in our series. A low rate of allergologist referral was observed. Emergency physicians must work closely with allergologists to ensure a better evaluation, long-term care and preventive management of patients with allergic diseases admitted to the ED.

Implications for urgent transfusion of uncrossmatched blood in the emergency department: The prevalence of clinically significant red cell antibodies within different patient groups.

Abstract: Objective: To define the prevalence of alloantibodies as a factor of age and underlying clinical disease, with particular relevance to the prediction of the safety of uncrossmatched blood in different demographic groups. Methods: A retrospective review was conducted of all immunohaematological studies on blood samples submitted to the blood bank of a tertiary referral hospital between January 1998 and December 1999. Results: A total of 27 968 antibody screens in 15 966 patients were analysed. When only clinically significant antibodies were considered, the total alloimmunization prevalence was 1.9% and the prevalence of antibodies capable of causing an immediate transfusion reaction was 0.6%. The prevalence of antibodies capable of causing an immediate transfusion reaction was 0.1% in the under 30 years of age group. Clinically significant antibodies were found in 5.1% in the haematology and oncology unit patients. The risk rises with age and female sex. Conclusion: We conclude that uncrossmatched blood is associated with low risk in patients < 30 years of age. The knowledge that patients have not been exposed to previous transfusion or pregnancy will reduce the risk even further.

A new drug free technique for reducing anterior shoulder dislocations

Abstract: Five cases of anterior shoulder dislocation are reported. The dislocations were reduced quickly, painlessly and without the use of drugs using the ‘Cunningham technique.’ The practice and theory of the technique are described. The ‘Cunningham technique’ is a useful single operator method of reducing anterior shoulder dislocations. Further research is being undertaken to reproduce the results in a larger patient group and also to examine how easily the technique can be taught.

Observational study of prehospital delays in patients with chest pain

Abstract: Method: A prospective observational study of prehospital times and events was undertaken on a target population of patients presenting with acute chest pain attributable to an acute coronary syndrome over a three month period. Results: Patients who decided to call the ambulance service were compared with patients who contacted any other service. Most patients who contact non-ambulance services are seen by general practitioners. The prehospital system time for 121 patients who chose to call the ambulance service first was significantly shorter than for 96 patients who chose to call another service (median 57 min v 107 min; p<0.001). Of the 42 patients thrombolysed in the emergency department, those who chose to call the ambulance service had significantly shorter prehospital system times (number 21 v 21; median 44 v 69 min; p<0.001). Overall time from pain onset to initiation of thrombolysis was significantly longer in the group of patients who called a non-ambulance service first (median 130 min v 248 min; p=0.005). Conclusions: Patient with acute ischaemic chest pain who call their general practice instead of the ambulance service are likely to have delayed thrombolysis. This is likely to result in increased mortality. The most beneficial current approach is for general practices to divert all patients with possible ischaemic chest pain onset within 12 hours direct to the ambulance service.

Beyond the 12 lead: review of the use of additional leads for the early electrocardiographic diagnosis of acute myocardial infarction.

Abstract: Despite known limitations, the standard 12 lead ECG is the principal risk stratification device for patients presenting with chest pain to the ED. However, it has a sensitivity of less than 60% for MI. One reason for this is that the standard placement of chest leads fails to interrogate many areas of the myocardium. Various workers have addressed this problem through the use of additional leads or body surface mapping. Additional leads on the posterior and right thoracic surface have been shown to give additional information, which may be important to the emergency physician. This review demonstrates the need for additional leads in the acute setting and makes recommendations about the utility of using additional leads in the ED.

The accuracy of external blood loss estimation by ambulance and hospital personnel.

Abstract: Objective: To determine if emergency personnel, either ambulance or hospital based, can estimate the volume of external blood loss accurately enough to be of potential clinical use in guiding fluid resuscitation. Methods: A total of 61 ambulance and 35 hospital personnel viewed nine scenarios consisting of volumes of blood (100 mL, 400 mL and 700 mL) spilt onto three surfaces — carpet, vinyl and a clothed manikin. They were asked to estimate the blood loss in each case. Results: Estimates of volumes of blood loss on all surfaces were generally inaccurate. Both ambulance and hospital groups were comparable in this regard. Hospital personnel had higher mean estimates than those of ambulance personnel. Of particular clinical relevance were the findings that blood loss on carpet was underestimated and small volumes on a clothed manikin were overestimated. Conclusion: External blood loss estimation by ambulance and hospital personnel is generally too inaccurate to be of clinical use.

Presumed Angel's trumpet (Brugmansia) poisoning: clinical effects and epidemiology.

Abstract: Objective: To investigate the pattern and epidemiology of anticholinergic plant poisoning, and to characterize its time course and clinical features. Methods: We reviewed all anticholinergic plant poisonings using a prospective database of all poisonings admitted to a major toxicology unit in Australia. All patients that presented with anticholinergic plant poisoning between July 1990 and June 2000 were included. Patient demographics, details of poisoning, diagnostic clinical features, adverse effects (seizures, arrhythmias, hypotension, accidental injury), and treatments required were obtained. Important diagnostic features were analysed and compared to previous studies. Results: Thirty-three patients were presumed to have ingested Brugmansia spp. (Angel's trumpet) based on their description of the plant; median age 18 years (interquartile range 16–20); 82% males. Thirty-one ingested a brewed tea or parts of the plant (flower). Thirty-one used it recreationally. Common clinical features were: mydriasis (100%), mean duration 29 h (SD 13) and delirium (88%) with a mean duration of 18 h (SD 12). Tachycardia only occurred in 11 of the 33 patients (33%). In 24 patients where the time of ingestion was certain, 7 of 8 (88%) patients presenting within 5 h had tachycardia and only 5 out of 16 (31%) presenting after 5 h had tachycardia. There were no deaths, seizures or arrhythmias (excepting tachycardia). One patient had hypotension and two sustained accidental traumatic injuries. Nineteen patients required sedation, mainly with benzodiazepines. Physostigmine was used diagnostically in eight cases. Conclusions: Anticholinergic plant abuse is sporadic in nature. Most cases were moderate in severity, requiring sedation only, and severe toxicity was rare. Mydriasis and delirium were the commonest features, the later having important implications for management.

Accidental poisoning in New Zealand.

Abstract: Objective: To examine mortality and morbidity associated with accidental poisoning in New Zealand for the period of 1993–97, and make comparisons with international trends. Methods: Poison Centre call data, and mortality and public hospital discharge data from the New Zealand Health Information Service were examined. Mortality and hospitalization rates were calculated. Statistical trends were examined using Poisson regression. Results: Poison Centre calls regarding household agents and therapeutics were most frequent. Accidental poisoning with analgesics, antipyretics and antirheumatics (18%) was a common cause of hospitalization. Children under 5 years had the highest hospitalization rates, but were less at risk of death by accidental poisoning than other age groups. Common causes of death from accidental poisoning included utility gas/carbon monoxide (16%), psychotropic agents (16%), and analgesics, etc. (15%). Mortality rates varied between 0.54 and 0.72/100 000 population. Conclusion: Mortality rates in New Zealand are lower than in many countries, but hospitalization rates are higher. Possible explanations and prevention implications are discussed.

The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department

Abstract: Objective: To determine if the use of a modified adult protocol that uses cervical spine imaging on presentation for the assessment of cervical spine injury in children improves clinical outcome. Methods: This is a case series study on all consecutive trauma patients presenting from April to July 2000 inclusive to the ED of a major paediatric trauma hospital. Children presenting to the ED with potential cervical spine injury (CSI) were identified using standard selection criteria. Patient demographics, mechanism of injury, method and time of presentation, associated injuries, radiological investigation and clinical outcome were recorded. The major outcome measures for this study were: time to clearance of the cervical spine, length of stay in the ED and admission to an in-hospital bed. Data were analysed for compliance to the protocol, this being the standard assessment pathway of cervical spine clearance used by our trauma service. Results: The trauma registry identified 1721 trauma presentations during the 4-month study period; 208 presentations representing 200 children with potential CSI were entered into the study. Males represented 72.5% of the study population, having a mean age of 8.32 years, although 29% were less than 5 years of age. The majority of presentations (69%) occurred outside of normal working hours. In 17.8% of cases the cervical spine was cleared based on clinical assessment alone, half less than 5 years of age. Compliance to the protocol occurred in 78% of presentations. However, when examined by age group, children 5 years of age or above were 1.5 times more likely to comply with the protocol as compared with younger children. Adequate plain imaging was not obtained in 18% of presentations, this group almost exclusively less than 5 years of age. There were no missed injuries and no short or long-term neurological sequelae reported during this study. There were no differences in time to clearance, length of stay and admission rate between compliant and non-compliant groups. Conclusions: Modified adult protocols for cervical spine clearance offer guidance in managing the majority of children suffering blunt trauma. However, we recommend caution in rigidly applying such protocols, especially to children of young age.

Validation of the Ottawa Ankle Rules in Australia.

Abstract: Objective: This study was a prospective validation of the Ottawa Ankle Rules (OAR) in Australia following appropriate education in the use of the rules. Methods: The OAR were applied to consecutive patients 18 years and over presenting with acute ankle and foot injuries to the ED of an urban teaching hospital. Results: Three hundred and thirty-three patients had 366 injuries. There were 43 fractures in 265 ankle injuries and 14 fractures in 101 foot injuries. Sensitivity was 100% for ankle (95% confidence interval (CI): 92–100) and midfoot fractures (95% CI: 77–100). Specificity was 15.8% (95% CI: 11–21) for ankle fractures and 20.7% (95% CI: 13–31) for midfoot fractures. Conclusion: The OAR had a sensitivity of 100% for ankle and midfoot fractures when used by both junior and senior physicians.

Suspected snakebite: One year prospective study of emergency department presentations

Abstract: AIM: Snakebite is an uncommon, but potentially life-threatening condition. The more common clinical scenario is suspected snake-bite. Our aim was to characterise the epidemiology, diagnosis and management of patients with suspected snakebites. METHODS: Prospective cohort study of patients presenting with suspected snakebites to a tertiary referral hospital serving a large rural region in tropical northern Australia where a standard admission protocol for suspected snakebites is used. RESULTS: Of 70 suspected snakebite cases, there were 45 definite bites: three severe envenomings (two western brown snakes [Pseudonaja nuchalis] and one mulga snake [Pseudechis australis]); seven mild/moderate envenomings by other snakes, two non-envenomings by identified P. nuchalis, five bites by identified non-venomous snakes and 28 definite bites without envenoming. The remaining 25 cases were either suspected bites (8), unlikely bites (15) and two people hit by snakes. Definite snake-bites occurred throughout the year, peaking in May and December. There were three severe envenomings (mainly coagulopathy), requiring antivenom treatment, but no deaths or major complications. Most patients had appropriate investigations. Of 47 venom detection kit swabs collected, 34 were not tested, venom was not detected in nine and was positive in the three envenomings with one false-positive tiger snake. Whole blood clotting time was highly sensitive for procoagulant coagulopathy and envenoming in this study. Median length of time from the bite to discharge was 20 h (interquartile range: 12-27). CONCLUSIONS: The study shows that although suspected snakebite was common, severe envenoming occurred in less than 5% of cases. The study supports the proposition that a structured approach and admission policy of suspected snakebites leads to the appropriate management of severe envenoming, with no cases discharged early and no cases of non-envenoming treated with antivenom.

Interrater reliability of injury coding in the Queensland Trauma Registry.

Abstract: The capacity to accurately code injury event details and use the Abbreviated Injury Scale and Injury Severity Score to group injuries according to severity, underpins the audit and review activities of the trauma registries throughout the world. In the interests of transparency and benchmarking between registries, we aimed to assess the interrater reliability of coding in the Queensland Trauma Registry. One hundred and twenty injury cases were randomly selected from the Queensland Trauma Registry database, stratified by hospital, severity and the coder who originally coded the chart. Cases were then recoded by six coders employed by the Queensland Trauma Registry. Coding was carried out by all raters simultaneously and independently. Interrater agreement between coders was high for external cause, intent, and place of injury with kappa scores for all interrater pairs being greater than 0.80, 0.58 and 0.44. Agreement between the six raters for Injury Severity Score was found to be very high (intraclass correlation coefficient of 0.9). The accuracy of coding in the Queensland Trauma Registry is sufficiently high to ensure that quality data are available for research, audit and review.

Skills retention for insertion of the Combitube and laryngeal mask airway.

Abstract: Objective: To determine if the skills to successfully ventilate using the laryngeal mask (The Laryngeal Mask Company Limited, Henley on Thames, United Kingdom) and Combitube (The Kendall Company, Mansfield, USA) can be retained after seven months. Methods: Nursing, medical and theatre staff from Dunedin Hospital were recruited in a prospective study. Subjects were taught to insert and ventilate an Ambuman manikin using both devices. Subjects were tested on their ability to ventilate the manikin with both devices within one month then following a six-month period. Results: A total of 101 subjects were recruited with 86 subjects retested at least six months later. Initial testing resulted in subjects successfully ventilating the manikin in 90% (laryngeal mask) and 92% (Combitube) of attempts. At retesting, successful ventilation was achieved in 85% (laryngeal mask) and 77% (Combitube) of attempts. The decline in skills level was significant for the Combitube only (95% CI 4% to 26%). Conclusion: The ability to successfully ventilate is better maintained with the laryngeal mask than the Combitube after seven months.