Integrated major haemorrhage management in the retrieval setting: Damage control resuscitation from referral to receiving facility

Major haemorrhage is a leading cause of death in critically ill or injured patients requiring medical retrieval and presents significant clinical and logistic challenges irrespective of patient location, primary pathophysiology or mode of transport. It is essential that all care providers involved in the retrieval patient pathway, including referring hospitals, ambulance services, retrieval teams and tertiary receiving centres, adopt a common approach to the management of this complex patient group through the use of retrieval‐specific, integrated protocols. These should incorporate the latest clinical evidence base, recognise the differences between primary and inter‐facility missions and clearly define the roles and responsibilities of the retrieval clinical coordinator. By unifying the response across services, the aim is to facilitate seamless transition of care with ongoing damage control resuscitation from point of referral, during transfer and on arrival at the receiving centre.     

Cardioembolic strokes resulting from a self‐inflicted needle puncture involving both sides of the heart

Foreign bodies in the heart are rare occurrences with a limited evidence base to guide recommendations on management. We report a case of multiple cardioembolic strokes as a result of a self‐inflicted sewing needle puncture from the anterior chest through the right ventricle and interventricular septum with its tip in the left ventricle close to the subvalvular apparatus in a 39‐year‐old psychiatric patient. We discuss issues surrounding decision making and ongoing care and highlight the importance of further follow‐up and reporting of cases to form a robust evidence base to guide future recommendations.     

Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study

Objective

Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations.

Methods

Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling.

Results

A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS.

Conclusion

Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.     

Are emergency department nurse practitioners homeless?

The professional body for nurses working in emergency medicine is the College of Emergency Nursing Australasia. The professional body for doctors working in emergency medicine is the Australasian College for Emergency Medicine (ACEM). There is no professional body for nurse practitioners working in emergency medicine. The clinical role of nurse practitioners in emergency medicine more closely resembles that of doctors rather than nurses. Associate membership in ACEM would recognise their role in treating patients and would enhance their access to relevant continued professional development as has been endorsed by ACEM. It would also facilitate their further integration into the body of those who autonomously treat patients in the ED.