Thread by @GaryPayinda

A summary thread from the great Emergency Medicine Australasia issue I finally read on the plane; @EMAJournal #foamed

Thom study in EMA: patients with unstable cervical #fractures can sit (29%), walk (63%), lack midline tenderness (27%), and have delayed presentation (20%).

@EMAJournal #emergencymedicine

surf injuries were mostly lower c-spine

NEXUS underperformed compared to Canadian C-spine.

#drowning and cervical CTs are not inextricably linked: don't automatically image unless signs of axial loading/very specific concerns

@EMAJournal [my $0.02 on immobilising (virtually) anyone prehospitally: cervical immobilisation is a myth: collars don't actually immobilise, and 'immobilisation' doesn't actually prevent neurological injury...it *does* however harm (eg aspiration and other harms)]

@EMAJournal over half of pt in Isle's trauma study had recreational drugs or psychoactive medications in their blood. lots of cannabis, alcohol, antidepressants in christchurch.

antidepressants associated with an elevated crash risk, quoted at 40%. interesting.

@EMAJournal australian study: over half of rest home patient transfers to the emergency department for #falls were "potentially avoidable". 76% had brain CT...none had a neurosurgical intervention. None. #ED

@EMAJournal it appears we are burning money on needless (unkind, disorienting) transfers and imaging on elderly with falls.

@EMAJournal IMO, need a non-doctor housecall service for rest homes; so much treatable help they could offer, not just falls, but treatment of urosepsis, chf, pneumonia, copd without coming to ED. who's doing this?

@EMAJournal one suggested way to address systemic ED inequities: automatic minimum triage 3 status for any indigenous patient presenting to ED. we know they get less and poorer medical care and have vastly worse outcomes. thoughts?

@EMAJournal a reminder: prothrombinex is not a panacea for bleeding in chronic liver disease, and may make things worse, like it does for DIC.

cited review: even in high-risk clinical areas and with prolonged use, there was little virus carriage on healthcare worker face #masks.

@EMAJournal good to know.

face masks reduced healthcare workers' rates of touching their mucosal surfaces.

published survey: wealthier people were less likely to call an ambulance needlessly. i dunno, they have way more options.

@EMAJournal if you had no petrol money, or no car, no family support, no money...yeah, you'd be more likely to call an ambulance, it doesn't seem unreasonable. as always, poverty is the underlying problem.
also, non-emergency scenarios could be open to interpretation: labour, lego in ear.

@EMAJournal could depend on the nuance of the situation.

love it: quote of a cohort study 61,000 arterial lines (vented #ICU pts): no mortality benefit to an art line. [IMO, a greatly overused intervention.] hello #VBG

@EMAJournal guideline mention: 7 days is the recommended change-over time for art lines. (hope we never get to the point ED patients are in ED for their 7 day change.)

48% of #FACEMs in NZ are heaped up in the cities. In Aus, it's 82%.
wild!

@EMAJournal specialists avoiding rural areas and regional hospitals like the plague. (as always, two different worlds for patients: haves and have nots; #rural patients firmly in the latter category.) any countries nailing this problem? subsidies, pay differentials?

@EMAJournal fascinating: NZ is *so* urbanised. Auckland is a juggernaut, dwarfing all else. only 16% of NZers are rural!? (28% in Oz)
mind-blowing: 1/3rd of New Zealand lives in Auckland.

Do you live in a rural area?

@EMAJournal the disability adjusted life year (DALY) burden increases by 1.4 times in very remote Aus areas compared to living in the city.

Solutions to the broken bones and brain injuries of the city #scooter industry?

@EMAJournal zero blood alcohol limits for e-scooter riders, reduced speed limits (this should be a no-brainer; cities could mandate this tomorrow if they wanted, one software update is all it would take), mandatory helmet use. lots of bad injuries are alcohol-related, and nighttime.

@EMAJournal ECMO. in this cohort, only 21 out of 61 cases were eligible for #ECMO. that's a helluva lot of transport of moribund patients. [IMO our ability to 'do something' vastly outweighs our ability to say 'enough is enough']

@EMAJournal on a related note: the very real possibility of being blamed by a lawyer or bureaucrat for missing an #AorticDissection can lead to ED docs CT scanning chest pain patients recklessly. we already scan 100 to catch one. how much worse can it get? potentially much worse.

@EMAJournal aortic dissection, IRAD registry: 20% dont have chest pain, 'tearing' or 'ripping' isn't sensitive...sudden and severe pain are better. 6% don't have any pain at all...but may have syncope, heart failure, or stroke. pulse deficits in only 30%...[not helpful].

@EMAJournal chest xr normal in 20% [even in hindsight.] ischaemic ecg in 25%: [uh-oh, can you say ACS misdiagnosis. ] overall AD mortality 27%

ADDRS-D-dimer, no thank you. unhelpful unless you live in a place where overscanning is rampant, this will just lead to more overscanning.

@EMAJournal CT angiogram 1:750 estimated additional lifetime cancer risk from radiation; dunno if i wholly buy this, as the study quotes an old citation; doses have dropped with newest generation scanners.

@EMAJournal authors posit a scenario where we cause 53 cancers and 40,000 to catch an additional two cases of #AorticDissection. [can quibble the numbers, but makes a good point. we've lost our minds thinking we'll get to Zero Risk in emergency medicine.]

@EMAJournal fwiw, case report: lewy body dementia/parkinson pt given haloperidol and droperidol. precipitating neuroleptic malignant syndrome. yeah, don't do that. theatre is your best place to find dantrolene or bromocriptine. [ED first stop: benzodiazepines, fluids, airway control.

@EMAJournal the tox treatment for nearly everything that excites you.]

#cannabinoid hyperemesis syndrome: a spicy disagreement between Aus and US factions in the back pages of EMA.

@EMAJournal my (anecdotal) conclusion: strongly associated with 'hot shower seeking'; chronic daily (often heavy) users; droperidol and iv fluids; assist with drug rehab.

other journals: unsurprisingly, flooding with IV fluids doesnt help pancreatitis (didn't we know this already?)

@EMAJournal routine IV bolus before intubation isn't magically effective at reducing hypotension or mortality. [prophylactic salt water proven ineffective, yet again.]

paeds: no cases of bacterial meningitis in febrile infants aged 29-60 days with positive UA.

@EMAJournal authors suggest avoiding the LP in this cohort if other features low risk (this doesn't hold true for infants <29 days); caution advised though; consider inflammatory markers, and don't forget HSV. #pediatrics

@EMAJournal names matter: calling #LowBackPain 'low back pain' is vastly preferable to calling it "lumbar radiculopathy" or "disc bulge"; the latter just heighten fear, medicalises a ubiquitous process, and generates unreasonable expectations of imaging and specialist referral for a…

@EMAJournal …problem that is common and normally self-limited.

EMJ study on shoulder #POCUS. In this study of 1206 patients, for shoulder dislocation ultrasound was 100% sensitive, 100% specific. For proximal humeral head fracture 97% and 99% respectively.

@EMAJournal Missed 6 Bankart lesions, and 2 greater tuberosity fx). -end- unroll @threadreaderapp