Comparison of different sepsis scoring systems and pathways: qSOFA, SIRS, Shapiro criteria and CEC SEPSIS KILLS pathway in bacteraemic and non-bacteraemic patients presenting to the emergency department.

BACKGROUND: Bacteraemia is associated with high morbidity and mortality, with delayed antibiotic treatment associated with poorer outcomes. Early identification is challenging, but clinically important. Multiple scoring systems have been developed to identify individuals in the broader categories of sepsis. We designed this study to assess the performance of existing scoring systems and pathways-CEC SEPSIS KILLS pathway (an Australian sepsis care package), quick sequential organ failure score (qSOFA), systemic inflammatory response syndrome (SIRS) and the Shapiro criteria. METHODS: This was a retrospective cohort study performed in two metropolitan hospitals in NSW, consisting of adult patients (> 18 years) with positive blood cultures containing a true pathogen and patients matched by age without positive blood cultures. Performance (sensitivity, specificity, and mortality prediction) of recognised sepsis and bacteraemia criteria and pathways-qSOFA, SIRS, Shapiro criteria and CEC SEPSIS KILLS pathway in the first 4 h following ED triage was assessed. RESULTS: There were 251 patients in each cohort. Sepsis-related mortality was higher in the bacteraemic group (OR 0.4, p = 0.03). Of the criteria studied, the modified Shapiro criteria had the highest sensitivity (88%) with modest specificity (37.85%), and qSOFA had the highest specificity (83.67%) with poor sensitivity (19.82%). SIRS had reasonable sensitivity (82.07%), with poor sensitivity (20.72%). The CEC SEPSIS pathway sensitivity of 70.1% and specificity of 71.1%. The SEPSIS KILLS was activated on only 14% of bacteraemic patients. CONCLUSION: The performance of all scoring systems and pathways was suboptimal in the identification of patients at risk of bacteraemia presenting to the emergency department.

Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy.

OBJECTIVE: This study was a prospective, randomized controlled trial of rapid sequence intubation (RSI) with cricoid pressure (CP) within the emergency department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration. METHOD: Patients > 18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive measured CP using weighing scales to target the ideal CP range (3.060-4.075 kg) or control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and esophageal samples were taken and underwent pepsin analysis. RESULTS: Fifty-four RSIs were analyzed (25 measured/29 control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0-50 seconds), both groups delivered in-range CP. During intubation (51-223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For 11 patients, pepsin was detected in the oropharyngeal sample, while three were positive for tracheal pepsin. Seven patients (four control/three measured) were treated for clinical aspiration during hospitalization. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned. CONCLUSION: Laryngoscopy provides a counter force to CP, which is negated to facilitate tracheal intubation. The concept that a static 3.060 to 4.075 kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study.

Effectiveness of cricoid pressure in preventing gastric aspiration during rapid sequence intubation in the emergency department: study protocol for a randomised controlled trial.

BACKGROUND: Cricoid pressure is considered to be the gold standard means of preventing aspiration of gastric content during Rapid Sequence Intubation (RSI). Its effectiveness has only been demonstrated in cadaveric studies and case reports. No randomised controlled trials comparing the incidence of gastric aspiration following emergent RSI, with or without cricoid pressure, have been performed. If improperly applied, cricoid pressure increases risk to the patient. The clinical significance of aspiration in the emergency department is unknown. This randomised controlled trial aims to; 1. Compare the application of the 'ideal" amount of force (30 - 40 newtons) to standard, unmeasured cricoid pressure and 2. Determine the incidence of clinically defined aspiration syndromes following RSI using a fibrinogen degradation assay previously described. METHODS/DESIGN: 212 patients requiring emergency intubation will be randomly allocated to either control (unmeasured cricoid pressure) or intervention groups (30 - 40 newtons cricoid pressure). The primary outcome is the rate of aspiration of gastric contents (determined by pepsin detection in the oropharyngeal/tracheal aspirates or treatment for aspiration pneumonitis up to 28 days post-intubation). Secondary outcomes are; correlation between aspiration and lowest pre-intubation Glasgow Coma Score, the relationship between detection of pepsin in trachea and development of aspiration syndromes, complications associated with intubation and grade of the view on direct largyngoscopy. DISCUSSION: The benefits and risks of cricoid pressure application will be scrutinised by comparison of the incidence of aspiration and difficult or failed intubations in each group. The role of cricoid pressure in RSI in the emergency department and the use of a pepsin detection as a predictor of clinical aspiration will be evaluated. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611000587909.

Lack of effect on blood alcohol level of swabbing venepuncture sites with 70% isopropyl alcohol.

OBJECTIVE: It is standard practice to clean the skin using a non-alcohol-containing swab before forensic blood alcohol sampling, because of the belief that the use of an alcohol-containing swab will contaminate the sample. The present study aimed to determine whether cleaning the skin with 70% isopropyl alcohol swabs, before venepuncture, alters measured blood alcohol level (BAL). METHODS: Volunteers aged >18 years had paired venous blood tests, which were drawn within 2 min of each other. One arm was swabbed with a 70% isopropyl alcohol swab and allowed to dry before venepuncture. The other was swabbed with saline, and these concurrent samples were used as controls. BAL was tested using the enzymatic method. Pathologists analysing the samples were blinded to the swabbing technique used. The mean differences and standard deviations of each of the paired samples were analysed using Student's t-test. RESULTS: Fifty-six paired venous blood samples were obtained from volunteers. Mean BAL in the isopropyl alcohol-swabbed group was 3.27 mg/dL with a standard deviation of 1.14 mg/dL. Mean BAL in the saline-swabbed group was 3.41 mg/dL with a standard deviation of 1.11 mg/dL. The mean difference was 0.14 mg/dL, with a standard error of 0.157. There was no statistically significant difference between the groups. CONCLUSIONS: The present study demonstrated that the use of 70% isopropyl alcohol swabs does not significantly affect BAL when used before venepuncture. This has implications that challenge current forensic blood alcohol sample acquisition.

Helicopter use in rural trauma.

OBJECTIVE: To profile a helicopter emergency medical service in rural Australia. To assess patient injury severities and outcomes. To compare missions involving ambulance officers with physicians. To determine any time advantage of the aircraft over ground transfer. METHODS: Intention-to-treat analysis using retrospective case note review of all helicopter emergency medical service trauma patients from January 2004 to November 2006. Global positioning system mapping technology was used to compare one-way road transfer times with two-way helicopter retrieval. RESULTS: Two hundred and twenty-two missions were identified from the helicopter log. Forty missions were aborted in flight. Of 182 patients transported, 11 records were incomplete, leaving 171 for analysis. Fifty (29%) patients transported had an Injury Severity Score (ISS) > 15; the average ISS was 12.30 (standard error of the mean 0.82). The average calculated distance flown was 160.4 nautical miles (standard error of the mean 5.29; range 28-360 nautical miles). There was no significant difference in ISS between ambulance officers and physician groups (t = -1.17, P = 0.25, 95% CI -7.37-1.91). There was no difference in the incidence of severe injury (ISS > 15, P = 0.39) or mortality (P = 0.33) when the groups were compared. Air transport was significantly faster beyond 100 km, with a mean difference of 48 min (P = 0.00). CONCLUSION: We could not identify a significant survival benefit attributable to the addition of a doctor, although numbers for this comparison were small. Predicting missions where flight physicians might provide benefit remain imprecise and should be a priority area for prospective evaluation. We have demonstrated that in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care.

Practice makes perfect? Evaluation of cricoid pressure task training for use within the algorithm for rapid sequence induction in critical care.

OBJECTIVE: To assess task training in cricoid pressure application suitable for incorporation into the algorithm for rapid sequence induction in acute care. METHOD: A blinded prospective direct observational study of 110 critical care staff of two hospitals in regional New South Wales. Each participant was instructed to apply blinded cricoid force within the target range of 30-40 N to a cricoid model mounted on a weighing scale and the result recorded. After up to 3 min of unblinded practice without coaching on the same model a repeat blinded application of force was recorded. The pre- and post-intervention results were compared. RESULTS: At the pre-intervention stage, 22 participants (20%) applied initial pressure within the target range, increasing to 57 (52%) at the post-intervention stage (chi(2) = 24.19, d.f. = 1, P < 0.01; odds ratio [OR] = 0.23; 95% confidence interval [CI] 0.12-0.44). The post-intervention results show a significant improvement in the number of participants achieving the target range in both nursing (chi(2) = 20.42, d.f. = 1, P < 0.01; OR = 0.18; 95% CI 0.08-0.42) and medical subgroups (chi(2) = 4.68, d.f. = 1, P = 0.03; OR = 0.34; 95% CI 0.11-1.02). The number applying force sufficient to prevent regurgitation, that is 30 N or greater, rose from 71 to 97 (65% to 88%) (chi(2) = 17.02, d.f. = 1, P < 0.01; OR = 0.24; 95% CI 0.11-0.51). The number applying in excess of 44 N fell from 41 to 25 (37% to 21%) (chi(2) = 5.54, d.f. = 1, P < 0.02; OR = 2.02; 95% CI 1.08-3.81). CONCLUSION: The application of cricoid force by critical care staff can be significantly improved by up to 3 min of practice on a simple task trainer.

Content analysis of Australian newspaper portrayals of emergency medicine.

OBJECTIVE: To evaluate portrayals of emergency medicine (EM) in Australian newspapers. METHOD: Systematic content analysis of articles about the ED in four major Australian newspapers. RESULTS: From July 2003 to June 2004 176 articles about the ED were published. Articles about ED overload were dominant (37.9% of all subjects identified). Articles about solutions to ED problems (16%) and errors (12.7%) were also prominent. Emergency physicians (EP) provided 13.5% of all of the commentary in the articles. Health administrators, spokespersons and politicians collectively constituted 44.3% of voices. The Australasian College for Emergency Medicine (ACEM) provided little commentary (4%). Overall 18% of articles portrayed EM in a positive light, 37% neutral and 45% negative. The ratio of negative to positive articles was 2.5:1. Page-one stories were mostly concerned with ED overload and errors and were predominantly negative. Positive articles (18%) most commonly covered solutions to problems, 'Life in the Emergency Department' or descriptions of staff involvement with interesting diseases. CONCLUSIONS: There is a significant media focus on ED problems and errors. The majority of comment comes from politicians and bureaucrats not EP or the ACEM and, overall, the articles examined portrayed EM in a negative light. EP and the ACEM should evaluate ways to improve the interface between the specialty and the media.

Assessment of cricoid pressure application by emergency department staff.

OBJECTIVE: To assess the accuracy of cricoid force applied by ED staff working in two hospitals based on the New South Wales central coast. METHODS: A prospective, observational study of 38 doctors and 69 nurses working in the ED. Each staff member was asked to demonstrate cricoid pressure using a model based on a set of weighing scales. Five attempts were measured and a mean value calculated for each participant. Subgroup analysis was also performed for specific variables of interest. RESULTS: Twenty-seven (25%) participants applied the target cricoid force. Of the 80 participants who were outside of the target range, 50 (63%) applied less than the target range and 30 (37%) applied more than the target range. No statistically significant difference was demonstrated for sex, age, qualification or years of experience and the ability to apply cricoid force within the target range. More candidates (27) applied the target range than those who correctly identified it (12). When methods of instruction were compared there was no difference between candidates with one and more than one modality of instruction (t-test: t (105) = -0.09, P = 0.9; 95% confidence interval [CI]-0.66-0.6) and the mean cricoid force applied. Those who had greater than one form of instruction applied correct cricoid force at the target range more often than those who had received only one form of instruction, this result was significant. (chi(2) = 4.24, d.f. = 1, P = 0.04; odds ratio = 2.6; 95% CI 1.03-6.41). CONCLUSION: The application of cricoid force by ED staff participating in the present study is unreliable, often providing inadequate protection against regurgitation. Training using a model integrating the concept of force is recommended. The role of cricoid pressure in rapid sequence induction needs to be further investigated.

Red-back spider envenomation in children in Central Australia.

OBJECTIVE: To describe the clinical spectrum of Red-back spider (RBS) envenomation in children up to 12 years of age. METHODS: Retrospective case notes review of children with a discharge diagnosis of RBS bite from January 1992 to June 2001. The setting was Alice Springs Hospital, the main paediatric hospital for the whole region of Central Australia. The patients were 54 children, comprising 39 Aboriginal and 15 non-Aboriginal children. RESULTS: Forty-six (85%) children had systemic envenomation. The three most common systemic features are irritability, hypertension and sweating; 35 (65%) children had all three systemic features. Forty-five (83%) received antivenom therapy. The clinical characteristics and outcomes showed no significant difference between children 4 and > 4 years of age. CONCLUSIONS: There is a high incidence of systemic envenomation due to RBS bite in children in Central Australia. The triad of irritability, hypertension and sweating in a previously well child is highly suggestive of latrodectism.